**4. Management of TMJ ankylosis**

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 ankylosis, usually noticed by dental practitioners [22].

#### **4.1. Management of TMJ ankylosis without severe dentofacial deformity**

To date, various treatment approaches have been described to achieve successful manage‐ ment of ankylosis [23-24]; however no single treatment with uniformly successful results has been assigned for all cases [4, 25-26]. The optimum selection of an adequate techni‐ que depends directly on the details of clinical situation of the patients and is highlighted particularly in patients' growing phase, since their consequent facial deformity could be significantly worsened during growth [27]. In the aforementioned patients, orthopedic treatment with functional appliances following surgical release of ankylosis is highly recommended.

**Possible treatment modalities** for cases without severe facial deformities include surgical excision of an ankylotic mass, gap arthroplasty and interpositional arthroplasty [16, 24]. These techniques may be supplemented by application of different autogenous or alloplas‐ tic materials to reconstruct the ramus and affected condylar segments [28-29].

**The first treatment option** is gap arthroplasty, which increases the gap between the articular cavity and ramus by means of a simple bone division (Figure 10). The modifications of this technique including increasing the gap alone to reduce the re-ankylosis may not be clinically effective [30].

The second category, interpositional arthroplasty addresses the main drawbacks of the first method, which is high recurrence rate [31]. In this technique, surgeons try to fill the gap with autogenous graft materials including skin, dermis, flap of temporal muscle, cartilage or even alloplastic materials like silastic (Figure 11 a-c). The placement of these materials prevents the recurrence possibility. TMJ reconstruction is the third treatment option commonly done by means of a costochondral graft. However, other autogenous graft sources like clavicular osteochondral graft, coronoid process graft or alloplastic condylar implants can be used to reconstruct the lost segments. Autogenous sources present donor site morbidity; however alloplastic grafts are procedures with significant disadvantages of implant fracture of foreign body reaction. Between autogenous sources, costochondral grafts represent the most variable growth behavior, particularly in growing children, as compared to coronoid process graft, which demonstrate more predictable growth behavior.

Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art http://dx.doi.org/10.5772/59165 419

**Figure 10.** Intra-operative view demonstrating gap arthroplasty technique.

been cited as a more potent surgical approach (32).

4) Lining of the joint with temporalis fascia or the remaining disk (16)

the ramus height of the affected side.

using rigid fixation (**Figure 12 a‐c**),

**the gap arthroplasty.** 

9

34).

**4. Management of TMJ ankylosis**

418 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

recommended.

effective [30].

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 ankylosis, usually noticed by dental practitioners [22].

To date, various treatment approaches have been described to achieve successful manage‐ ment of ankylosis [23-24]; however no single treatment with uniformly successful results has been assigned for all cases [4, 25-26]. The optimum selection of an adequate techni‐ que depends directly on the details of clinical situation of the patients and is highlighted particularly in patients' growing phase, since their consequent facial deformity could be significantly worsened during growth [27]. In the aforementioned patients, orthopedic treatment with functional appliances following surgical release of ankylosis is highly

**Possible treatment modalities** for cases without severe facial deformities include surgical excision of an ankylotic mass, gap arthroplasty and interpositional arthroplasty [16, 24]. These techniques may be supplemented by application of different autogenous or alloplas‐

**The first treatment option** is gap arthroplasty, which increases the gap between the articular cavity and ramus by means of a simple bone division (Figure 10). The modifications of this technique including increasing the gap alone to reduce the re-ankylosis may not be clinically

The second category, interpositional arthroplasty addresses the main drawbacks of the first method, which is high recurrence rate [31]. In this technique, surgeons try to fill the gap with autogenous graft materials including skin, dermis, flap of temporal muscle, cartilage or even alloplastic materials like silastic (Figure 11 a-c). The placement of these materials prevents the recurrence possibility. TMJ reconstruction is the third treatment option commonly done by means of a costochondral graft. However, other autogenous graft sources like clavicular osteochondral graft, coronoid process graft or alloplastic condylar implants can be used to reconstruct the lost segments. Autogenous sources present donor site morbidity; however alloplastic grafts are procedures with significant disadvantages of implant fracture of foreign body reaction. Between autogenous sources, costochondral grafts represent the most variable growth behavior, particularly in growing children, as compared to coronoid process graft,

tic materials to reconstruct the ramus and affected condylar segments [28-29].

which demonstrate more predictable growth behavior.

**4.1. Management of TMJ ankylosis without severe dentofacial deformity**

**Figure 11. Interpositional arthroplasty of an ankylotic condyle by means of square‐shaped silastic graft material, a) Selected alloplastic silastic‐based graft material, b) Insertion of the alloplastic silastic material, c) final position of the alloplastic material filling up the entire space created by Figure 11.** Interpositional arthroplasty of an ankylotic condyle by means of square-shaped silastic graft material, a) Se‐ lected alloplastic silastic-based graft material, b) Insertion of the alloplastic silastic material, c) final position of the allo‐ plastic material filling up the entire space created by the gap arthroplasty.

**An approved international surgical protocol** consists of 9‐steps to take before and after surgery.

1) Aggressive total resection of the ankylotic segment in the condylar TMJ region. Recently, complete excision of the bony mass has been questioned regarding the increasing probability of the recurrence rate (10). The underlying postulation was that leaving the opposing bony cut surface of the condyles after complete excision increase the amount of clot formation on dead space, which ultimately results in the formation of dense fibrous bridges that impede future mandibular movement (32). Partial osteotomy of the region with minimal clot formation has

2) Coronoidectomy on the affected side (ipsilateral) which usually elongates in long‐standing ankylosis and prevents intra‐operative maximal opening because of the restriction. The autogenous bone achieved by this step can be used as a source of graft material to re‐establish

3) If the above‐mentioned procedures do not result in normal maximum opening (more than 35 mm) without excessive force, the opposite coronoid (contralateral) must also be removed.

Remnants of the meniscus can serve as a barrier to prevent direct bony contacts and further fusion between condylar heads and glenoid fossa. However, there is controversy in the literature regarding the main role of the disc on the development of ankylosis (7). In many traumatized cases, it has been shown that the ankylosis can occur even in the presence of an intact meniscus in the joint space (33‐

5) Reconstruction of the ramus segment with costochondral grafts in growing patients if possible

**An approved international surgical protocol** consists of 9-steps to take before and after surgery.


Remnants of the meniscus can serve as a barrier to prevent direct bony contacts and further fusion between condylar heads and glenoid fossa. However, there is controversy in the literature regarding the main role of the disc on the development of ankylosis [7]. In many traumatized cases, it has been shown that the ankylosis can occur even in the presence of an intact meniscus in the joint space [33-34].

**5.** Reconstruction of the ramus segment with costochondral grafts in growing patients if possible using rigid fixation (Figure 12 a-c),

**Figure 12. Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the TMJ ankylotic mass through a preauricular excision, b) submandibular incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of Figure 12.** Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the TMJ ankylotic mass through a preauricular excision, b) submandibular incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of the ankylotic mass and fixation of the costochondral graft by means of fixation screws.

6) Intra‐operative open bite creation on the affected side to permit settling of the bone graft, which should be maintained by a hybrid orthodontic appliance for 3‐6 months (**Figure 13 a**) (35). Simple removable functional appliance (Hybrid) with lingual and buccal shields on the affected side to encourage dental eruption and a bite block on the contralateral side to impede the eruption (**Figure 13 b**). In adult cases, however, considering the absence of passive dental eruption, the open bite should be managed by means of orthodontic brackets and light intermaxillary elastics (**Figure 14 a,**

**Figure 13. a) A hybrid functional appliance consist of two set of shields (lingual and buccal) to facilitate dental eruption on the affected side and acrylic bite block to impede dental eruption on**

**the ankylotic mass and fixation of the costochondral graft by means of fixation screws.**

**a b**

**the opposite site, b) A hybrid functional appliance in place**

**a b c**

10

**b**).

**the ankylotic mass and fixation of the costochondral graft by means of fixation screws.**

**a b c**

**Figure 12. Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the TMJ ankylotic mass through a preauricular excision, b) submandibular incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of**

**6.** Intra-operative open bite creation on the affected side to permit settling of the bone graft, which should be maintained by a hybrid orthodontic appliance for 3-6 months (Figure 13 a) [35]. Simple removable functional appliance (Hybrid) with lingual and buccal shields on the affected side to encourage dental eruption and a bite block on the contralateral side to impede the eruption (Figure 13 b). In adult cases, however, considering the absence of passive dental eruption, the open bite should be managed by means of orthodontic brackets and light intermaxillary elastics (Figure 14 a, b). removable functional appliance (Hybrid) with lingual and buccal shields on the affected side to encourage dental eruption and a bite block on the contralateral side to impede the eruption (**Figure 13 b**). In adult cases, however, considering the absence of passive dental eruption, the open bite should be managed by means of orthodontic brackets and light intermaxillary elastics (**Figure 14 a, b**).

**a b**

**An approved international surgical protocol** consists of 9-steps to take before and after

**1.** Aggressive total resection of the ankylotic segment in the condylar TMJ region. Recently, complete excision of the bony mass has been questioned regarding the increasing probability of the recurrence rate [10]. The underlying postulation was that leaving the opposing bony cut surface of the condyles after complete excision increase the amount of clot formation on dead space, which ultimately results in the formation of dense fibrous bridges that impede future mandibular movement [32]. Partial osteotomy of the region with minimal clot formation has been cited as a more potent surgical approach [32].

**2.** Coronoidectomy on the affected side (ipsilateral) which usually elongates in longstanding ankylosis and prevents intra-operative maximal opening because of the restric‐ tion. The autogenous bone achieved by this step can be used as a source of graft material

**3.** If the above-mentioned procedures do not result in normal maximum opening (more than 35 mm) without excessive force, the opposite coronoid (contralateral) must also be

Remnants of the meniscus can serve as a barrier to prevent direct bony contacts and further fusion between condylar heads and glenoid fossa. However, there is controversy in the literature regarding the main role of the disc on the development of ankylosis [7]. In many traumatized cases, it has been shown that the ankylosis can occur even in the presence of an

**5.** Reconstruction of the ramus segment with costochondral grafts in growing patients if

**a b c**

**Figure 12.** Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the TMJ ankylotic mass through a preauricular excision, b) submandibular incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of the ankylotic mass and fixation of the costochondral graft by

**Figure 12. Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the TMJ ankylotic mass through a preauricular excision, b) submandibular incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of**

6) Intra‐operative open bite creation on the affected side to permit settling of the bone graft, which should be maintained by a hybrid orthodontic appliance for 3‐6 months (**Figure 13 a**) (35). Simple removable functional appliance (Hybrid) with lingual and buccal shields on the affected side to encourage dental eruption and a bite block on the contralateral side to impede the eruption (**Figure 13 b**). In adult cases, however, considering the absence of passive dental eruption, the open bite should be managed by means of orthodontic brackets and light intermaxillary elastics (**Figure 14 a,**

**Figure 13. a) A hybrid functional appliance consist of two set of shields (lingual and buccal) to facilitate dental eruption on the affected side and acrylic bite block to impede dental eruption on**

11

**Treatment**

**the ankylotic mass and fixation of the costochondral graft by means of fixation screws.**

**a b**

**the opposite site, b) A hybrid functional appliance in place**

to re-establish the ramus height of the affected side.

420 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**4.** Lining of the joint with temporalis fascia or the remaining disk [16]

surgery.

removed.

10

**b**).

means of fixation screws.

intact meniscus in the joint space [33-34].

possible using rigid fixation (Figure 12 a-c),

**occlusion (From Behnia H: A Textbook of Advanced Oral and Maxillofacial Surgery ISBN 978‐953‐**

8) Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re‐

ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue contraction in

**a b c**

**Figure 15. a‐c) Adjunctive physiotherapy appliances that are used as aiding appliances during the**

Recurrence of ankylosis and restricted mandibular movement are the most common complications

after surgical management of the ankylotic mass. Following surgical protocol and also adequate

compliance with postoperative adjunctive therapy might prevent these complications (31). The final

postoperative result is dependent directly on the selected surgical procedure, surgical technique, and

A 5‐year‐old girl with a history of left condylar trauma at age 2, with progressive facial asymmetry

and deviation of the dental midlines due to left condylar ankylosis (**Figure 16 a**). There was no

history of any other congenital malformation or childhood illness. On clinical examination her jaw

deviated slightly to the left on closure and showed limited right lateral excursion. The ankylotic mass

9) Additional corrective surgery at the later stages when growth is completed

7) Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),

**Figure 13. a) A hybrid functional appliance consist of two set of shields (lingual and buccal) to facilitate dental eruption on the affected side and acrylic bite block to impede dental eruption on the opposite site, b) A hybrid functional appliance in place Figure 13.** a) A hybrid functional appliance consist of two set of shields (lingual and buccal) to facilitate dental erup‐ tion on the affected side and acrylic bite block to impede dental eruption on the opposite site, b) A hybrid functional appliance in place

10 **Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite on the affected side; note the degree of anterior open bite, b) Intraoral photograph of the final Figure 14.** a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite on the affected side; note the degree of anterior open bite, b) Intraoral photograph of the final occlusion (From Behnia H: A Textbook of Advanced Oral and Maxillofacial Surgery ISBN 978-953-51-1146-7. chapter 16, Distraction Osteogenesis; 2013).

**51‐1146‐7. chapter 16, Distraction Osteogenesis; 2013).**

the healing stage (**Figure 15 a‐c**).

**physiotherapy phase.** 

attention to postsurgical physiotherapy.

**Unilateral condylar ankylosis**

**a b**

**a b**

**7.** Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks), 8) Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re‐

7) Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),

**Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite on the affected side; note the degree of anterior open bite, b) Intraoral photograph of the final**

**8.** Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re-ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue contraction in the healing stage (Figure 15 a-c). ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue contraction in the healing stage (**Figure 15 a‐c**).

**Figure 15. a‐c) Adjunctive physiotherapy appliances that are used as aiding appliances during the physiotherapy phase. Figure 15.** a-c) Adjunctive physiotherapy appliances that are used as aiding appliances during the physiotherapy phase.

9) Additional corrective surgery at the later stages when growth is completed **9.** Additional corrective surgery at the later stages when growth is completed

Recurrence of ankylosis and restricted mandibular movement are the most common complications after surgical management of the ankylotic mass. Following surgical protocol and also adequate compliance with postoperative adjunctive therapy might prevent these complications (31). The final postoperative result is dependent directly on the selected surgical procedure, surgical technique, and attention to postsurgical physiotherapy. Recurrence of ankylosis and restricted mandibular movement are the most common compli‐ cations after surgical management of the ankylotic mass. Following surgical protocol and also adequate compliance with postoperative adjunctive therapy might prevent these complica‐ tions [31]. The final postoperative result is dependent directly on the selected surgical proce‐ dure, surgical technique, and attention to postsurgical physiotherapy.

#### **Treatment Unilateral condylar ankylosis** *4.1.1. Treatment*

#### A 5‐year‐old girl with a history of left condylar trauma at age 2, with progressive facial asymmetry *4.1.1.1. Unilateral condylar ankylosis*

11 and deviation of the dental midlines due to left condylar ankylosis (**Figure 16 a**). There was no A 5-year-old girl with a history of left condylar trauma at age 2, with progressive facial asymmetry and deviation of the dental midlines due to left condylar ankylosis (Figure 16 a). There was no history of any other congenital malformation or childhood illness. On clinical examination her jaw deviated slightly to the left on closure and showed limited right lateral excursion. The ankylotic mass of the left condyle was demonstrated clearly on the MRI (Figure 16 b). An autogenous costochondral graft to reconstruct the left condyle had been done at age 5, which left an intraoperative open bite on the left side (Figure 16 c, d). A removable functional hybrid appliance was provided for the patient immediately after surgery to maintain the graft in a suitable position and let the posterior teeth on contralateral side erupt. This appliance opened the bite on the left side and brought the chin to the midline (Figure 16 e). The patient cooperated very well in the postsurgical phase with removable appliance and functional exercises of the jaws. One year after the orthodontic phase, the patient demonstrated an acceptable occlusion and facial symmetry (Figure 16 f).

patient demonstrated an acceptable occlusion and facial symmetry (**Figure 16 f**). Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art http://dx.doi.org/10.5772/59165 423

history of any other congenital malformation or childhood illness. On clinical examination her jaw deviated slightly to the left on closure and showed limited right lateral excursion. The ankylotic mass of the left condyle was demonstrated clearly on the MRI (**Figure 16 b**). An autogenous costochondral graft to reconstruct the left condyle had been done at age 5, which left an intraoperative open bite on the left side (**Figure 16 c, d**). A removable functional hybrid appliance was provided for the patient immediately after surgery to maintain the graft in a suitable position and let the posterior teeth on contralateral side erupt. This appliance opened the bite on the left side and brought the chin to the midline (**Figure 16 e**). The patient cooperated very well in the postsurgical phase with removable appliance and functional exercises of the jaws. One year after the orthodontic phase, the

**a b c**

**7.** Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),

8) Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re‐ ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue contraction in

7) Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),

**Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite on the affected side; note the degree of anterior open bite, b) Intraoral photograph of the final occlusion (From Behnia H: A Textbook of Advanced Oral and Maxillofacial Surgery ISBN 978‐953‐**

**8.** Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re-ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue

**a b c**

**Figure 15. a‐c) Adjunctive physiotherapy appliances that are used as aiding appliances during the**

**Figure 15.** a-c) Adjunctive physiotherapy appliances that are used as aiding appliances during the physiotherapy

Recurrence of ankylosis and restricted mandibular movement are the most common complications after surgical management of the ankylotic mass. Following surgical protocol and also adequate compliance with postoperative adjunctive therapy might prevent these complications (31). The final postoperative result is dependent directly on the selected surgical procedure, surgical technique, and

Recurrence of ankylosis and restricted mandibular movement are the most common compli‐ cations after surgical management of the ankylotic mass. Following surgical protocol and also adequate compliance with postoperative adjunctive therapy might prevent these complica‐ tions [31]. The final postoperative result is dependent directly on the selected surgical proce‐

A 5‐year‐old girl with a history of left condylar trauma at age 2, with progressive facial asymmetry and deviation of the dental midlines due to left condylar ankylosis (**Figure 16 a**). There was no

A 5-year-old girl with a history of left condylar trauma at age 2, with progressive facial asymmetry and deviation of the dental midlines due to left condylar ankylosis (Figure 16 a). There was no history of any other congenital malformation or childhood illness. On clinical examination her jaw deviated slightly to the left on closure and showed limited right lateral excursion. The ankylotic mass of the left condyle was demonstrated clearly on the MRI (Figure 16 b). An autogenous costochondral graft to reconstruct the left condyle had been done at age 5, which left an intraoperative open bite on the left side (Figure 16 c, d). A removable functional hybrid appliance was provided for the patient immediately after surgery to maintain the graft in a suitable position and let the posterior teeth on contralateral side erupt. This appliance opened the bite on the left side and brought the chin to the midline (Figure 16 e). The patient cooperated very well in the postsurgical phase with removable appliance and functional exercises of the jaws. One year after the orthodontic phase, the patient demonstrated an

9) Additional corrective surgery at the later stages when growth is completed

dure, surgical technique, and attention to postsurgical physiotherapy.

acceptable occlusion and facial symmetry (Figure 16 f).

**9.** Additional corrective surgery at the later stages when growth is completed

contraction in the healing stage (Figure 15 a-c).

the healing stage (**Figure 15 a‐c**).

**physiotherapy phase.** 

attention to postsurgical physiotherapy.

*4.1.1.1. Unilateral condylar ankylosis*

**Unilateral condylar ankylosis**

**51‐1146‐7. chapter 16, Distraction Osteogenesis; 2013).**

422 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**a b**

11

**Treatment**

*4.1.1. Treatment*

phase.

**Figure 16. a) Facial view of a 5 year‐old boy, b) MRI before any orthodontic intervention, c) postoperative openbite immediately after surgery to free the ankylotic condyle, d) Insertion of a hybrid functional appliance for differential dental eruption, e) occlusion of the patient. The remarkable improvement from unilateral condylar ankylosis and subsequent normal symmetric Figure 16.** a) Facial view of a 5 year-old boy, b) MRI before any orthodontic intervention, c) postoperative openbite immediately after surgery to free the ankylotic condyle, d) Insertion of a hybrid functional appliance for differential dental eruption, e) occlusion of the patient. The remarkable improvement from unilateral condylar ankylosis and sub‐ sequent normal symmetric growth of facial structure was achieved. The functional appliance was also worn at night during the growth period. f) Final facial view

#### **growth of facial structure was achieved. The functional appliance was also worn at night during the growth period. f) Final facial view 4.2. Management of temporomandibular joint ankylosis combined with severe dentofacial deformity**

b) **Management of temporomandibular joint ankylosis combined with severe dentofacial deformity.** Patients with a history of persistent ankylosis usually demonstrate significant facial asymmetry. In addition to previously described surgery to release the ankylotic mass, these patients usually should undergo a second procedure to compensate developed facial asymmetries. This second procedure can range from a conservative genioplasty to orthognathic surgery of both jaws. Recently, distraction osteogenesis has become popular as another possible treatment option for the second phase (36). However, precise monitoring of the distraction direction is an important consideration during this Patients with a history of persistent ankylosis usually demonstrate significant facial asymme‐ try. In addition to previously described surgery to release the ankylotic mass, these patients usually should undergo a second procedure to compensate developed facial asymmetries. This second procedure can range from a conservative genioplasty to orthognathic surgery of both jaws. Recently, distraction osteogenesis has become popular as another possible treatment option for the second phase [36]. However, precise monitoring of the distraction direction is an important consideration during this procedure. The final result of the distraction osteo‐ genesis must be maintained via help of other functional appliances in growing patients [37]. Other adjunctive cosmetic surgical techniques like fat injection also can be applied to com‐ pensate the remaining asymmetry of the face [30].

12 **Surgical treatment with costochondral graft** (CCG) and distraction osteogenesis (DO) in cases with temporomandibular joint ankylosis associated with severe dentofacial deformities is

usually effective and quite reliable (Figure 17 a,b). Most of the assigned patients had significant mandibular retrognathia and asymmetry. Distraction usually started on day 7 after surgery. temporomandibular joint ankylosis associated with severe dentofacial deformities is usually effective and quite reliable (**Figure 17 a,b**). Most of the assigned patients had significant mandibular

retrognathia and asymmetry. Distraction usually started on day 7 after surgery.

**Surgical treatment with costochondral graft** (CCG) and distraction osteogenesis (DO) in cases with

procedure. The final result of the distraction osteogenesis must be maintained via help of other functional appliances in growing patients (37). Other adjunctive cosmetic surgical techniques like fat

**Figure 17. A case with unilateral distraction osteogenesis after receiving costochondral graft. Lateral cephalometry of the patient before (left) and after (right) distractor insertion. Figure 17.** A case with unilateral distraction osteogenesis after receiving costochondral graft. Lateral cephalometry of the patient before (left) and after (right) distractor insertion.

#### **Treatment** *4.2.1. Treatment*

13

orthodontic treatment.

#### **Bilateral condylar ankylosis** *4.2.1.1. Bilateral condylar ankylosis*

A 21‐year‐old male with a history of trauma at age 9, presented severe mandibular deficiency, micrognathia with restricted excursive and protrusive mandibular movement secondary to bilateral condylar ankylosis (**Figure 18 a**). The dental history of the patient revealed that, he had previously undergone an autogenous costochondral graft after bilateral condylectomy one year later, but re‐ ankylosis occurred. This whole procedure was repeated again one year after failure; however it did A 21-year-old male with a history of trauma at age 9, presented severe mandibular deficiency, micrognathia with restricted excursive and protrusive mandibular movement secondary to bilateral condylar ankylosis (Figure 18 a). The dental history of the patient revealed that, he had previously undergone an autogenous costochondral graft after bilateral condylectomy one year later, but re-ankylosis occurred. This whole procedure was repeated again one year after failure; however it did not fully address the patient's problem.

not fully address the patient's problem. **The treatment plan** was to lengthen the mandible with bilateral distraction osteogenesis, which could advance the soft tissue volume simultaneously. Orthodontic treatment including extraction of first premolars on both sides due to preparation of adequate overjet was conducted on both sides. The extraction space was subsequently closed with moderate anchorage on both sides. Circumferential osteotomies were done on both side of the ramus and unilateral extraoral distractors (multiguided Leibinger) and were fixed in place (**Figure 18 b**). Considering the asymmetric representation of mandibular retrusion, the amount of mandibular advancement in the distraction phase was not equal on the right and left sides. During distraction phase, posterior open bite developed on the right side which was corrected by continuous application of cross elastic traction **The treatment plan** was to lengthen the mandible with bilateral distraction osteogenesis, which could advance the soft tissue volume simultaneously. Orthodontic treatment including extraction of first premolars on both sides due to preparation of adequate overjet was con‐ ducted on both sides. The extraction space was subsequently closed with moderate anchorage on both sides. Circumferential osteotomies were done on both side of the ramus and unilateral extraoral distractors (multiguided Leibinger) and were fixed in place (Figure 18 b). Consider‐ ing the asymmetric representation of mandibular retrusion, the amount of mandibular advancement in the distraction phase was not equal on the right and left sides. During distraction phase, posterior open bite developed on the right side which was corrected by continuous application of cross elastic traction via fixed orthodontics (Figure 18 c). Upper and lower Hawley retainers with embedded wire on the occlusal surface of the upper posterior teeth were provided for the patient after finishing orthodontic treatment.

via fixed orthodontics (**Figure 18 c**). Upper and lower Hawley retainers with embedded wire on the occlusal surface of the upper posterior teeth were provided for the patient after finishing Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art http://dx.doi.org/10.5772/59165 425

usually effective and quite reliable (Figure 17 a,b). Most of the assigned patients had significant mandibular retrognathia and asymmetry. Distraction usually started on day 7 after surgery.

**Figure 17. A case with unilateral distraction osteogenesis after receiving costochondral graft.**

**Figure 17.** A case with unilateral distraction osteogenesis after receiving costochondral graft. Lateral cephalometry of

A 21‐year‐old male with a history of trauma at age 9, presented severe mandibular deficiency, micrognathia with restricted excursive and protrusive mandibular movement secondary to bilateral condylar ankylosis (**Figure 18 a**). The dental history of the patient revealed that, he had previously undergone an autogenous costochondral graft after bilateral condylectomy one year later, but re‐ ankylosis occurred. This whole procedure was repeated again one year after failure; however it did

A 21-year-old male with a history of trauma at age 9, presented severe mandibular deficiency, micrognathia with restricted excursive and protrusive mandibular movement secondary to bilateral condylar ankylosis (Figure 18 a). The dental history of the patient revealed that, he had previously undergone an autogenous costochondral graft after bilateral condylectomy one year later, but re-ankylosis occurred. This whole procedure was repeated again one year

**The treatment plan** was to lengthen the mandible with bilateral distraction osteogenesis, which could advance the soft tissue volume simultaneously. Orthodontic treatment including extraction of first premolars on both sides due to preparation of adequate overjet was conducted on both sides. The extraction space was subsequently closed with moderate anchorage on both sides. Circumferential osteotomies were done on both side of the ramus and unilateral extraoral distractors (multiguided Leibinger) and were fixed in place (**Figure 18 b**). Considering the asymmetric representation of mandibular retrusion, the amount of mandibular advancement in the distraction phase was not equal on the right and left sides. During distraction phase, posterior open bite developed on the right side which was corrected by continuous application of cross elastic traction via fixed orthodontics (**Figure 18 c**). Upper and lower Hawley retainers with embedded wire on the occlusal surface of the upper posterior teeth were provided for the patient after finishing

**The treatment plan** was to lengthen the mandible with bilateral distraction osteogenesis, which could advance the soft tissue volume simultaneously. Orthodontic treatment including extraction of first premolars on both sides due to preparation of adequate overjet was con‐ ducted on both sides. The extraction space was subsequently closed with moderate anchorage on both sides. Circumferential osteotomies were done on both side of the ramus and unilateral extraoral distractors (multiguided Leibinger) and were fixed in place (Figure 18 b). Consider‐ ing the asymmetric representation of mandibular retrusion, the amount of mandibular advancement in the distraction phase was not equal on the right and left sides. During distraction phase, posterior open bite developed on the right side which was corrected by continuous application of cross elastic traction via fixed orthodontics (Figure 18 c). Upper and lower Hawley retainers with embedded wire on the occlusal surface of the upper posterior

**Lateral cephalometry of the patient before (left) and after (right) distractor insertion.**

after failure; however it did not fully address the patient's problem.

teeth were provided for the patient after finishing orthodontic treatment.

the patient before (left) and after (right) distractor insertion.

424 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

*4.2.1.1. Bilateral condylar ankylosis*

**Surgical treatment with costochondral graft** (CCG) and distraction osteogenesis (DO) in cases with temporomandibular joint ankylosis associated with severe dentofacial deformities is usually effective and quite reliable (**Figure 17 a,b**). Most of the assigned patients had significant mandibular

procedure. The final result of the distraction osteogenesis must be maintained via help of other functional appliances in growing patients (37). Other adjunctive cosmetic surgical techniques like fat

injection also can be applied to compensate the remaining asymmetry of the face (30).

retrognathia and asymmetry. Distraction usually started on day 7 after surgery.

13

orthodontic treatment.

**Treatment**

**Bilateral condylar ankylosis**

*4.2.1. Treatment*

not fully address the patient's problem.

**Figure 18.** a) Pre-distraction facial and intraoral appearance. Significant mandibular deficiency is apparent. b) Circum‐ ferential osteotomies were made at the body of the right and left ramus and then custom-made unidirectional extraoral distractors were fixed in place. The mandible was advanced by 7 mm. The posterior open bite was created at the right side as a result of mandibular lengthening. Orthodontic triangle elastics were used concomitant with fixed orthodontic appliance to manage the posterior right open bite. c) Frontal facial view after debonding.
