**3. Diagnosis and clinical features of TMJ ankylosis**

Maximum mouth opening in the presence of pain or without it is a clinical indicator of traumatized condyles [12]. In addition to routine extra and intraoral photographs, supple‐ mental diagnostic records may be needed for complete diagnosis of each case. Towne's projection, posteroanterior and cone beam CT (3D) radiographs are commonly used for this purpose (Figure 2 a, b).

Due to the flexibility of bone, it is possible to open the mandible to some extent, particularly in unilateral ankylotic cases [13]. Long-standing TMJ ankylosis can result in functional loss and facial deformity of affected individuals. In growing patients (mostly under 15 years) lack of adequate growth at the condyles, which are the main growth centers of the mandible, forward and downward movement of the mandible does not occur [13]. This growth retarda‐ tion can result in a distorted mandibular structure in all three dimensions, highlighted mostly on sagittal views. Furthermore, deepening of the antegonial notch following continuous subperiosteal bone formation at the angles may be seen in most of the affected. However, Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art http://dx.doi.org/10.5772/59165 413

underlying reason for development of the ankylotic mass following trauma. Observed hemorrhage

contains different cellular pathways activated by bone morphogenic proteins (BMPs) and tumoral

growth factors (TGFs) (9). However, a study on human subjects, revealed that hematoma in the joint

space does not always result in bony ankylosis (2). This excessive bone mass does not have a

neoplastic nature, but has the potential of continual growth (10). The presence of abnormal bony

mass may restrict mandibular movement, which subsequently may lead in loss of the functional

matrix of bone and muscle interaction, and consequently result in growth failure (11). Inadequately

treated or excessive treatment of condylar fractures may lead to growth retardation or growth

excess, respectively (3). Therefore, the best treatment steps for post‐traumatic ankylosis and

Maximum mouth opening in the presence of pain or without it is a clinical indicator of traumatized

condyles (12). In addition to routine extra and intraoral photographs, supplemental diagnostic

records may be needed for complete diagnosis of each case. Towne's projection, posteroanterior and

cone beam CT (3D) radiographs are commonly used for this purpose (**Figure 2 a, b**).

resulting growth abnormality is prevention.

3. **Diagnosis and clinical features of TMJ ankylosis**

the restricted condyle is seen (**Figure 3 a‐c**). On the other hand, in bilateral ankylosis, more limited range of interincisal opening and absence of maxillary occlusal canting is observed. Patients with **Figure 2.** a) Posteroanterior view of a condylar neck fracture, b) Coronal section of computer tomography scan of an‐ other adult patient with unilateral condylar fracture on the right side.

bilateral ankylosis develop retrognathia, short posterior facial height and openbite with possible

excessive localized bone formation [4]. Most of the animal studies consider intra-capsular hematoma as the main underlying reason for development of the ankylotic mass following trauma. Observed hemorrhage contains different cellular pathways activated by bone morphogenic proteins (BMPs) and tumoral growth factors (TGFs) [9]. However, a study on human subjects, revealed that hematoma in the joint space does not always result in bony ankylosis [2]. This excessive bone mass does not have a neoplastic nature, but has the potential of continual growth [10]. The presence of abnormal bony mass may restrict mandibular movement, which subsequently may lead in loss of the functional matrix of bone and muscle interaction, and consequently result in growth failure [11]. Inadequately treated or excessive treatment of condylar fractures may lead to growth retardation or growth excess, respectively [3]. Therefore, the best treatment steps for post-traumatic ankylosis and resulting growth

**Figure 1.** A 5-year-old girl with bilateral condylar ankylosis of unknown etiology (no history of trauma or infection). a) Extraoral facial photograph of the patient demonstrate the upper occlusal canting with the help of a tongue depressor, b) Intraoral photograph shows midline deviation, mandibular shift and increased overjet of the patient, c) three dimen‐

**Figure 1. A 5‐year‐old girl with bilateral condylar ankylosis of unknown etiology (no history of trauma or infection). a) Extraoral facial photograph of the patient demonstrate the upper occlusal canting with the help of a tongue depressor, b) Intraoral photograph shows midline deviation, mandibular shift and increased overjet of the patient, c) three dimensional cone beam computer**

The pathogenesis of the TMJ ankylosis is described by a sequence of events. The increased intra‐ articular vascular supply at the traumatized joint develops fibrosis and ultimately excessive localized bone formation (4). Most of the animal studies consider intra‐capsular hematoma as the main

**a b c**

**COMPREHENSIVE MANAGEMENT OF TEMPOROMANDIBULAR**

Temporomandibular joint (TMJ) ankylosis is one of the most challenging TMJ disorders that can negatively affect oral related daily functions like mastication, speech and hygiene (1,2). The accepted definition of ankylosis is the bony or fibrous tissue fusion between articular surfaces including the meniscus, glenoid fossa and condylar heads (3). Consequently, jaw functions like the maximal incisal opening (MIO) and lateral excursive movements progressively decrease. This chapter describes the most important issues of early and late management of TMJ ankylosis in both children and adults.

Trauma to the TMJ has been cited as the most common underlying reason responsible for ankylosis; however, local infections (e.g. otitis media) and systemic disorders (e.g. rheumatoid arthritis) also can also cause unilateral or bilateral TMJ ankylosis in some cases (4‐7). By improving the immediate management protocol of condylar fracture and proper application of antibiotics to fully address ear infections, the prevalence of ankylosis has decreased significantly in recent years. In addition to the common etiologic factors of TMJ condylar ankylosis, some affected infants with unknown etiological

**JOINT ANKYLOSIS: STATE OF THE ART**

Hossein Behnia, Azita Tehranchi and Farnaz Younessian

Additional information is available at the end of the chapter

2. **Etiology and pathogenesis of TMJ ankylosis**

412 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

factors have been reported in the literature (**Figure 1 a‐c**) (8).

1. **Introduction**

Maximum mouth opening in the presence of pain or without it is a clinical indicator of traumatized condyles [12]. In addition to routine extra and intraoral photographs, supple‐ mental diagnostic records may be needed for complete diagnosis of each case. Towne's projection, posteroanterior and cone beam CT (3D) radiographs are commonly used for this

Due to the flexibility of bone, it is possible to open the mandible to some extent, particularly in unilateral ankylotic cases [13]. Long-standing TMJ ankylosis can result in functional loss and facial deformity of affected individuals. In growing patients (mostly under 15 years) lack of adequate growth at the condyles, which are the main growth centers of the mandible, forward and downward movement of the mandible does not occur [13]. This growth retarda‐ tion can result in a distorted mandibular structure in all three dimensions, highlighted mostly on sagittal views. Furthermore, deepening of the antegonial notch following continuous subperiosteal bone formation at the angles may be seen in most of the affected. However,

abnormality is prevention.

1

purpose (Figure 2 a, b).

**3. Diagnosis and clinical features of TMJ ankylosis**

**reconstruction of the patient demonstrates the facial asymmetry.**

sional cone beam computer reconstruction of the patient demonstrates the facial asymmetry.

ankylosis in patients older than 15 years of age experience mild facial deformities concomitant with significant functional loss. Depending on the type of ankylosis (unilateral or bilateral) clinical features can vary. upper airway obstruction and severely convex facial profile (**Figure 4 a, b**) (15). **Figure 2. a) Posteroanterior view of a condylar neck fracture, b) Coronal section of computer tomography scan of another adult patient with unilateral condylar fracture on the right side.**

In the case of unilateral ankylosis, the patient also develops a mandibular asymmetry and subdivision malocclusion [14]. Furthermore, in unilateral cases canting of the upper occlusal surface thoughtto be caused by compensatory vertical eruption ofthe posterior maxillary teeth ipsilateraltotherestrictedcondyleis seen(Figure3a-c).Ontheotherhand,inbilateralankylosis, morelimitedrangeofinterincisalopeningandabsenceofmaxillaryocclusalcantingisobserved. Patientswithbilateralankylosisdevelopretrognathia, shortposteriorfacialheightandopenbite with possible upper airway obstruction and severely convex facial profile (Figure 4 a, b) [15]. Due to the flexibility of bone, it is possible to open the mandible to some extent, particularly in unilateral ankylotic cases (13). Long‐standing TMJ ankylosis can result in functional loss and facial deformity of affected individuals. In growing patients (mostly under 15 years) lack of adequate growth at the condyles, which are the main growth centers of the mandible, forward and downward movement of the mandible does not occur (13). This growth

retardation can result in a distorted mandibular structure in all three dimensions, highlighted

**Figure 3. A 3‐year‐old girl with unilateral condylar ankylosis following trauma at birth, a) on facial examination, the patient presented with facial asymmetry, shortened ramus height, jaw deviation and the chin was noticeably deviated to the left and the maxilla was canted downward on the Figure 3.** A 3-year-old girl with unilateral condylar ankylosis following trauma at birth, a) on facial examination, the patient presented with facial asymmetry, shortened ramus height, jaw deviation and the chin was noticeably deviated to the left and the maxilla was canted downward on the right side. b) The mandibular border became flat and elongat‐ ed on the unaffected side and round on the affected side. The asymmetry is usually the least at the cranial base area and becomes worse at the lower parts including the chin.

**right side. b) The mandibular border became flat and elongated on the unaffected side and round on the affected side. The asymmetry is usually the least at the cranial base area and becomes**

3

2

**worse at the lower parts including the chin.**

**Figure 4. An 18‐year‐old girl with bilateral condylar ankylosis. a) Long term effect of bilateral condylar ankylosis in a growing adolescent, which result in limited mouth opening, micrognathia and absent neck chin angle. b) The profile view is helpful to assess anteroposterior and vertical Figure 4.** An 18-year-old girl with bilateral condylar ankylosis. a) Long term effect of bilateral condylar ankylosis in a growing adolescent, which result in limited mouth opening, micrognathia and absent neck chin angle. b) The profile view is helpful to assess anteroposterior and vertical facial imbalance as well as aid in the determination of etiology of the asymmetry. C) 3D CT scan.

#### **facial imbalance as well as aid in the determination of etiology of the asymmetry. C) 3D CT scan. Prevention of TMJ ankylosis following trauma:**

**Prevention of TMJ ankylosis following trauma:** Regaining normal range of mandibular movement should begin as soon as possible after trauma. Many clinicians recommended a few days (5‐7) of no‐intervention immediately after the injury. This phase allows resolution of pain and swelling of the TMJ before reestablishment of normal range of movement (16). However, care must be taken not to overextend this phase regarding ankylosis development. Excellent compliance of the affected individuals with physiotherapy and functional appliances immediately after trauma is an essential part of future growth and development. Failure Regaining normal range of mandibular movement should begin as soon as possible after trauma. Many clinicians recommended a few days [5-7] of no-intervention immediately after the injury. This phase allows resolution of pain and swelling of the TMJ before reestablishment of normal range of movement [16]. However, care must be taken not to overextend this phase regarding ankylosis development. Excellent compliance of the affected individuals with physiotherapy and functional appliances immediately after trauma is an essential part of future growth and development. Failure to achieve a high level of compliance to physiotherapy and application of intraoral appliances, increase the risk of future ankylosis, which would be more problematic for patients as time passes.

#### to achieve a high level of compliance to physiotherapy and application of intraoral appliances, **3.1. Early management in childhood**

4

increase the risk of future ankylosis, which would be more problematic for patients as time passes. a. **Early management in childhood** Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal range of movement. In most cases, if the normal range of movement can be achieved, the TMJ will heal without any functional complication. When the patient is able to reach maximal opening, even in the presence of pain, the simplest prevention regimen would be insertion of a removable appliance, which guides the mandible into its correct position during closure. The design and fabrication of different types of removable appliances depends on the clinical situation of each patient, but commonly all are fabricated from a construction bite in which advances the mandible on the affected Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal range of movement. In most cases, if the normal range of movement can be achieved, the TMJ will heal without any functional complication. When the patient is able to reach maximal opening, even in the presence of pain, the simplest prevention regimen would be insertion of a removable appliance, which guides the mandible into its correct position during closure. The design and fabrication of different types of removable appliances depends on the clinical situation of each patient, but commonly all are fabricated from a construction bite in which advances the mandible on the affected side more than the contralateral side in addition to concise maxillary and mandibular midlines. The major difficulty with construction bite is that the clinician must be able to guide the mandible to the proper position, rapidly and accurately. Different types of appliances and various combinations of components can be incorporated in

side more than the contralateral side in addition to concise maxillary and mandibular midlines. The

these appliances to meet individual requirements. Depending on compliance and age of the affected child, we use four different techniques: for more secure retention (**Figure 6‐a**). 3‐ Usage of bi‐zygomatic suspension wires in more severe cases in the absence of patient for more secure retention (**Figure 6‐a**). 3‐ Usage of bi‐zygomatic suspension wires in more severe cases in the absence of patient

compliance and age of the affected child, we use four different techniques:

compliance and age of the affected child, we use four different techniques:

major difficulty with construction bite is that the clinician must be able to guide the mandible to the proper position, rapidly and accurately. Different types of appliances and various combinations of components can be incorporated in these appliances to meet individual requirements. Depending on

major difficulty with construction bite is that the clinician must be able to guide the mandible to the proper position, rapidly and accurately. Different types of appliances and various combinations of components can be incorporated in these appliances to meet individual requirements. Depending on

1‐ Two simple removable Hawley appliances attached together while the patient is in centric

1‐ Two simple removable Hawley appliances attached together while the patient is in centric

2‐ Fixed functional appliance with the aid of cement luting agent on the primary molars bands

2‐ Fixed functional appliance with the aid of cement luting agent on the primary molars bands


**Figure 5. Two simple removable Hawley appliances attached together is the most common appliance used to guide the patient into symmetric position. Figure 5.** Two simple removable Hawley appliances attached together is the most common appliance used to guide the patient into symmetric position.

**Figure 6. a) Fixed functional appliance with molar bands that can hold the mandible in its correct position full‐time, b and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics. Figure 6. a) Fixed functional appliance with molar bands that can hold the mandible in its correct position full‐time, b and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics. Figure 6.** a) Fixed functional appliance with molar bands that can hold the mandible in its correct position full-time, b and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics.

Despite the improvements, removable appliances are not a practical way to manage more severe situations that require extra manipulation of the TMJ fracture. A closed reduction often is useful to Despite the improvements, removable appliances are not a practical way to manage more severe situations that require extra manipulation of the TMJ fracture. A closed reduction often is useful to Despite the improvements, removable appliances are not a practical way to manage more severe situations that require extra manipulation of the TMJ fracture. A closed reduction often is useful to re-establish normal jaw function as a next step [17]. In fact, if the fractured condyle is still within the articular fossa, there is an opportunity to heal in a quite adequate functional

5

5

4

**a b c**

**Figure 4.** An 18-year-old girl with bilateral condylar ankylosis. a) Long term effect of bilateral condylar ankylosis in a growing adolescent, which result in limited mouth opening, micrognathia and absent neck chin angle. b) The profile view is helpful to assess anteroposterior and vertical facial imbalance as well as aid in the determination of etiology of

Regaining normal range of mandibular movement should begin as soon as possible after trauma. Many clinicians recommended a few days [5-7] of no-intervention immediately after the injury. This phase allows resolution of pain and swelling of the TMJ before reestablishment of normal range of movement [16]. However, care must be taken not to overextend this phase regarding ankylosis development. Excellent compliance of the affected individuals with physiotherapy and functional appliances immediately after trauma is an essential part of future growth and development. Failure to achieve a high level of compliance to physiotherapy and application of intraoral appliances, increase the risk of future ankylosis, which would be

Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal range of movement. In most cases, if the normal range of movement can be achieved, the TMJ will heal without any functional complication. When the patient is able to reach maximal opening, even in the presence of pain, the simplest prevention regimen would be insertion of a removable appliance, which guides the mandible into its correct position during closure. The design and fabrication of different types of removable appliances depends on the clinical situation of each patient, but commonly all are fabricated from a construction bite in which advances the mandible on the affected side more than the contralateral side in addition to concise maxillary and mandibular midlines. The major difficulty with construction bite is that the clinician must be able to guide the mandible to the proper position, rapidly and accurately. Different types of appliances and various combinations of components can be incorporated in

**Prevention of TMJ ankylosis following trauma:**

**Prevention of TMJ ankylosis following trauma:**

414 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

more problematic for patients as time passes.

**3.1. Early management in childhood**

the asymmetry. C) 3D CT scan.

a. **Early management in childhood**

**Figure 4. An 18‐year‐old girl with bilateral condylar ankylosis. a) Long term effect of bilateral condylar ankylosis in a growing adolescent, which result in limited mouth opening, micrognathia and absent neck chin angle. b) The profile view is helpful to assess anteroposterior and vertical facial imbalance as well as aid in the determination of etiology of the asymmetry. C) 3D CT scan.**

Regaining normal range of mandibular movement should begin as soon as possible after trauma. Many clinicians recommended a few days (5‐7) of no‐intervention immediately after the injury. This phase allows resolution of pain and swelling of the TMJ before reestablishment of normal range of movement (16). However, care must be taken not to overextend this phase regarding ankylosis development. Excellent compliance of the affected individuals with physiotherapy and functional appliances immediately after trauma is an essential part of future growth and development. Failure to achieve a high level of compliance to physiotherapy and application of intraoral appliances, increase the risk of future ankylosis, which would be more problematic for patients as time passes.

Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal range of movement. In most cases, if the normal range of movement can be achieved, the TMJ will heal without any functional complication. When the patient is able to reach maximal opening, even in the presence of pain, the simplest prevention regimen would be insertion of a removable appliance, which guides the mandible into its correct position during closure. The design and fabrication of different types of removable appliances depends on the clinical situation of each patient, but commonly all are fabricated from a construction bite in which advances the mandible on the affected side more than the contralateral side in addition to concise maxillary and mandibular midlines. The

position, only by maintaining the occlusion. This technique is preferred over open reduction due to high success rate, less complications and technical problems and also less remnant facial scars [18]. However, clinical decision on the most appropriate type of treatment must be made considering different individualized factors like patient age, medical history, risk of infection, and risk of chronic pain, risk of scarring or nerve injury, and also presence of other concomitant facial, mandibular or cranial fractures [19]. Conservative management of condylar fractures is still the preferred option, however, in rare cases of condylar displacement into the middle cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction is selected [17]. The advantages of open treatment for condylar fractures would be the possibility of restoring the anatomical position of the fragments and disc, and subsequently immediate functional movement of the jaw, which greatly avoids the development of ankylosis of the traumatized joint [20]. of scarring or nerve injury, and also presence of other concomitant facial, mandibular or cranial fractures (19). Conservative management of condylar fractures is still the preferred option, however, in rare cases of condylar displacement into the middle cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction is selected (17). The advantages of open treatment for condylar fractures would be the possibility of restoring the anatomical position of the fragments and disc, and subsequently immediate functional movement of the jaw, which greatly avoids the development of ankylosis of the traumatized joint (20).

#### *3.1.1. Treatment* **Treatment**

#### *3.1.1.1. Unilateral condylar fracture* A 4‐year‐old boy was brought in approximately five hours after being hit on the left side of the face.

**Unilateral condylar fracture**

A 4-year-old boy was brought in approximately five hours after being hit on the left side of the face. He complained of pain on the left side (Figure 7 a). The impressions of upper and lower arch with limited jaw opening were performed and an attached upper and lower Hawley appliance was fabricated to guide the patient into correct closure (Figure 7 b). The condyle of the affected side healed and positive outcomes were maintained during a 1-year follow-up (Figure 7 c and Figure 8 a, b). He complained of pain on the left side (**Figure 7 a**). The impressions of upper and lower arch with limited jaw opening were performed and an attached upper and lower Hawley appliance was fabricated to guide the patient into correct closure (**Figure 7 b**). The condyle of the affected side healed and positive outcomes were maintained during a 1‐year follow‐up (**Figure 7 c and Figure 8 a, b**).

**Figure 7. a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appliance inserted for further guidance of the lower arch. c) Frontal facial view at Figure 7.** a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appli‐ ance inserted for further guidance of the lower arch. c) Frontal facial view at the end of active treatment.

#### **the end of active treatment. 3.2. Early management in adulthood**

6

Sometimes adult patients suffer severe trauma to the condyles, particularly as a part of a catastrophic event [21]. Although, because of absence of required growth in later stages of life, this restricted condylar growth might not result in severe facial deformities, but it may result inlimitedmandibularfunction.Recentimprovementsintreatmenttechniquesincludingadvent

**Figure 8. Same patient shown in Figure 7. a) Note the presence of condylar neck fracture at posteroanterior projection radiograph immediately before treatment with removable appliance. b)**

**a b**

**a b c**

**Figure 7. a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appliance inserted for further guidance of the lower arch. c) Frontal facial view at**

of scarring or nerve injury, and also presence of other concomitant facial, mandibular or cranial fractures (19). Conservative management of condylar fractures is still the preferred option, however, in rare cases of condylar displacement into the middle cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction is selected (17). The advantages of open treatment for condylar fractures would be the possibility of restoring the anatomical position of the fragments and disc, and subsequently immediate functional movement of the jaw, which greatly

A 4‐year‐old boy was brought in approximately five hours after being hit on the left side of the face. He complained of pain on the left side (**Figure 7 a**). The impressions of upper and lower arch with limited jaw opening were performed and an attached upper and lower Hawley appliance was fabricated to guide the patient into correct closure (**Figure 7 b**). The condyle of the affected side healed and positive outcomes were maintained during a 1‐year follow‐up (**Figure 7 c and Figure 8 a,**

avoids the development of ankylosis of the traumatized joint (20).

**Treatment**

**b**).

**Unilateral condylar fracture**

position, only by maintaining the occlusion. This technique is preferred over open reduction due to high success rate, less complications and technical problems and also less remnant facial scars [18]. However, clinical decision on the most appropriate type of treatment must be made considering different individualized factors like patient age, medical history, risk of infection, and risk of chronic pain, risk of scarring or nerve injury, and also presence of other concomitant facial, mandibular or cranial fractures [19]. Conservative management of condylar fractures is still the preferred option, however, in rare cases of condylar displacement into the middle cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction is selected [17]. The advantages of open treatment for condylar fractures would be the possibility of restoring the anatomical position of the fragments and disc, and subsequently immediate functional movement of the jaw, which greatly avoids the development of ankylosis

of scarring or nerve injury, and also presence of other concomitant facial, mandibular or cranial fractures (19). Conservative management of condylar fractures is still the preferred option, however, in rare cases of condylar displacement into the middle cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction is selected (17). The advantages of open treatment for condylar fractures would be the possibility of restoring the anatomical position of the fragments and disc, and subsequently immediate functional movement of the jaw, which greatly

A 4-year-old boy was brought in approximately five hours after being hit on the left side of the face. He complained of pain on the left side (Figure 7 a). The impressions of upper and lower arch with limited jaw opening were performed and an attached upper and lower Hawley appliance was fabricated to guide the patient into correct closure (Figure 7 b). The condyle of the affected side healed and positive outcomes were maintained during a 1-year follow-up

**a b c**

**Figure 7.** a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appli‐

Sometimes adult patients suffer severe trauma to the condyles, particularly as a part of a catastrophic event [21]. Although, because of absence of required growth in later stages of life, this restricted condylar growth might not result in severe facial deformities, but it may result inlimitedmandibularfunction.Recentimprovementsintreatmenttechniquesincludingadvent

ance inserted for further guidance of the lower arch. c) Frontal facial view at the end of active treatment.

**a b**

**Figure 7. a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appliance inserted for further guidance of the lower arch. c) Frontal facial view at**

**Figure 8. Same patient shown in Figure 7. a) Note the presence of condylar neck fracture at posteroanterior projection radiograph immediately before treatment with removable appliance. b)**

A 4‐year‐old boy was brought in approximately five hours after being hit on the left side of the face. He complained of pain on the left side (**Figure 7 a**). The impressions of upper and lower arch with limited jaw opening were performed and an attached upper and lower Hawley appliance was fabricated to guide the patient into correct closure (**Figure 7 b**). The condyle of the affected side healed and positive outcomes were maintained during a 1‐year follow‐up (**Figure 7 c and Figure 8 a,**

avoids the development of ankylosis of the traumatized joint (20).

of the traumatized joint [20].

416 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Unilateral condylar fracture**

*3.1.1.1. Unilateral condylar fracture*

(Figure 7 c and Figure 8 a, b).

**the end of active treatment.**

**3.2. Early management in adulthood**

*3.1.1. Treatment*

**Treatment**

**b**).

6

Sometimes adult patients suffer severe trauma to the condyles, particularly as a part of a catastrophic event (21). Although, because of absence of required growth in later stages of life, this **Figure 8.** Same patient shown in Figure 7. a) Note the presence of condylar neck fracture at posteroanterior projection radiograph immediately before treatment with removable appliance. b) Follow-up radiograph of the patient which re‐ veals adequate alignment of the fractured bony segment after 1-year.

restricted condylar growth might not result in severe facial deformities, but it may result in limited

b. **Early management in adulthood**

removable appliances (21).

of temporary anchorage devices (TAD) can help clinicians manage the other jaw fractures presenting with the traumatized condyles. In contrast to the traditional techniques like intermaxillary wire fixations, application of TADs does not restrict the range of normal functional movements. In addition, comparing their application in growing patients, TADs could be inserted in mature bony structures of the jaws without any additional risk regarding possible damage to un-erupted dental crypts. This approach removes the necessity of pres‐ ence of enough remaining dentition to be used as guidance of jaw movements (Figure 9 a-c). With the help of these TADs and temporary light interarch elastics one can guide directional remodelingoftraumatizedcondylarsegments,inamannersimilartoremovableappliances[21]. mandibular function. Recent improvements in treatment techniques including advent of temporary anchorage devices (TAD) can help clinicians manage the other jaw fractures presenting with the traumatized condyles. In contrast to the traditional techniques like intermaxillary wire fixations, application of TADs does not restrict the range of normal functional movements. In addition, comparing their application in growing patients, TADs could be inserted in mature bony structures of the jaws without any additional risk regarding possible damage to un‐erupted dental crypts. This approach removes the necessity of presence of enough remaining dentition to be used as guidance of jaw movements (**Figure 9 a‐c**). With the help of these TADs and temporary light interarch elastics one can guide directional remodeling of traumatized condylar segments, in a manner similar to 6 **Figure 8. Same patient shown in Figure 7. a) Note the presence of condylar neck fracture at posteroanterior projection radiograph immediately before treatment with removable appliance. b)**

**a b c**

**Figure 9. a) Settling of the occlusion and guidance of proper healing procedure by means of TADs and light intermaxillary elastics in an adult patient, b) orthodontic brackets were bonded on teeth to correct the remaining dental malposition, c) final treatment result (From Tehranchi A: Rapid, Figure 9.** a) Settling of the occlusion and guidance of proper healing procedure by means of TADs and light intermax‐ illary elastics in an adult patient, b) orthodontic brackets were bonded on teeth to correct the remaining dental malpo‐ sition, c) final treatment result (From Tehranchi A: Rapid, conservative, multidisciplinary miniscrew-assisted approach for treatment of mandibular fractures following plane crash Dent Res J. 2013 Sep-Oct; 10: 678–684).

**conservative, multidisciplinary miniscrew‐assisted approach for treatment of mandibular fractures**

Treatment of TMJ ankylosis is an excellent example of an important principle in the timing of the treatment: because of devastating effects on future growth, presence of condylar ankylosis in growing patients is an indication for early treatment; in contrast, condylar ankylosis in adult patients must be treated considering the extent of functional limitation of mandibular movement. In many clinical situations pain is uncommon and limited range of opening is the first sign of condylar

To date, various treatment approaches have been described to achieve successful management of ankylosis (23‐24); however no single treatment with uniformly successful results has been assigned

a) **Management of TMJ ankylosis without severe dentofacial deformity**

**following plane crash Dent Res J. 2013 Sep‐Oct; 10: 678–684).**

ankylosis, usually noticed by dental practitioners (22).

4. **Management of TMJ ankylosis**

7
