Case of the fortnight
Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery       

Release of TMJ Ankylosis and Distraction Osteogenesis of Mandible

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A 16 year old girl was referred to us with inability to open her mouth since childhood.  She also had facial asymmetry.  She was only taking liquids and though speech was possible she was not communicating well.  She was also shy, suffering from a lack of confidence and reluctant to go to school.

On detailed discussions with her father, it came to light that she had (right) ear infection as an infant following which she gradually developed difficulty in mouth opening.  She had no other medical illness.

On examination she was frail and thin.   She had complete trismus of her mouth (inability to open) with gross facial asymmetry especially in relation to the mandible (lower jaw) thus affecting the lower half of her face.  The chin was deviated to the right side and the left side of her face appeared flattened.  She also had crowding and malaligned teeth in both the jaws.

CT: CT scan revealed bony ankylosis (fusion) of the right tempromandibular joint which was causing the trismus. The right side of the mandible was smaller when compared to the left side.

Treatment:

She primarily had 2 problems i.e. facial deformity and inability to open her mouth, which needed correction.  Her surgery was done in 2 stages.

Stage 1 – Distraction osteogenesis of the mandible to correct the asymmetry and at the same time bring it forward.  This not only helps in improving her appearance but also improves the tongue space thus helping her sleep better and reduce snoring.  This stage lasted 3 months. 

Stage II – In the next stage the ankylotic (bony) mass in relation to the right TM joint was resected and a gap of 2cms created to achieve mouth opening.

Distraction in Progress	Resection of Ankylotic mass

Present status:

She is comfortable with adequate mouth opening thus enabling her to eat solid foods after about 13 years.  Her improved facial appearance has also increased her confidence and she interacts freely with her friends and family. She needs regular mouth opening exercises to prevent the joint from fusing again.

Discussion:

Ankylosis of the TM joints is a debilitating condition causing Trismus.  This also affects the growth of the mandible as the condylar cartilage which is part of the lower joint is a growth centre for the mandible.  Any direct trauma with immobilization or persistent ear joint infections can lead to ankylosis.  If it occurs at a very early age it affects the growth of the mandible as seen in the above case.  If such a case presents at a later stage then correction of the facial deformity is also as important as releasing the ankylosis.