Int. J. Oral Maxillofac. Surg.

2014; 43: 14681472

http://dx.doi.org/10.1016/j.ijom.2014.08.010, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Gap arthroplasty of
temporomandibular joint
ankylosis by transoral access: a
case series

R. Rajan, N. V. V. Reddy, A. Potturi,

D. Jhawar, P. V. Muralidhar,
B. Reddy
Department of Oral and Maxillofacial Surgery,
SVS Institute of Dental Sciences,
Mahaboobnagar, Andhra Pradesh, India

R. Rajan, N.V.V. Reddy, A. Potturi, D. Jhawar, P.V. Muralidhar, B. Reddy: Gap

arthroplasty of temporomandibular joint ankylosis by transoral access: a case series.
Int. J. Oral Maxillofac. Surg. 2014; 43: 14681472. # 2014 International Association
of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This article describes a technique of gap arthroplasty in temporomandibular

joint (TMJ) ankylosis performed by transoral access. The treatment of TMJ
ankylosis by creating an adequate gap is of paramount importance in preventing any
future recurrence and this can be achieved only when good access is gained to this
complex anatomical joint. Five patients with TMJ ankylosis (eight TMJ) were
treated by gap arthroplasty using an intraoral approach. The average mouth opening
before surgery was 8.6 mm and the average mouth opening achieved postsurgery
was 37.9 mm. The average follow-up time was 13 months and none of the patients
had any recurrence or significant complications during or after surgery. Our
technique relies on the use of a stable landmark to trace the superior-most extent of
the ankylotic mass thereby facilitating the removal of the entire mass including the
medial extent. We found that even though transoral access is technically
challenging and took an average time of 84 min, it has many advantages over
conventional extraoral approaches in terms of facial scars and facial nerve injury.
The authors also emphasize the importance of good postoperative physiotherapy
and presurgical patient counselling to prevent future recurrences.

Temporomandibular joint (TMJ) ankylosis is a common condition in India. In

spite of attempts to prevent its incidence
by timely and appropriate management
of mandibular condyle fractures in both
paediatric and adult populations, it is still
seen quite frequently. Ankylosis of the
TMJ is an extremely debilitating condition, especially when it affects the joint
0901-5027/01201468 + 05

in its growing stages. Apart from causing

severe facial disfigurement, it also alters
the patients eating habits and speech
ability. It aggravates psychological
stress, prevents the patient from maintaining good oral hygiene resulting in
dental decay and the loss of multiple
teeth, and negatively affects quality of
life.1

Key words: gap arthroplasty; transoral access;

temporomandibular joint ankylosis.
Accepted for publication 27 August 2014
Available online 17 September 2014

The treatment of ankylosis is often

challenging and many surgical techniques
have been reported in the literature. Since
the times of Esmarch (1851), who was
credited with performing the first ever
osteotomy for ankylosis, to the times of
Abbe (1880) and Risdon (1934), who
introduced the concepts of gap arthroplasty and interpositional arthroplasty,

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Transoral gap arthroplasty for TMJ ankylosis

1469

Table 1. Details and outcomes of the patients treated.

Mouth
Mouth
opening Decrease
Preop. opening
mouth immediately Follow-up at the last in mouth
Patient
Type
Duration of
period
No. Age Sex Ankylosis Aetiology (Sawhney) opening postop.
follow-up opening Complications surgery
1
2
3
4

8
12
24
16

12 M Bilateral

M
M
F
M

Bilateral
Unilateral
Unilateral
Bilateral

Trauma
Trauma
Trauma
Trauma

II
I
I
II

Trauma

II

8 mm
14 mm
12 mm
5 mm

35 mm
38 mm
42 mm
33.6 mm

4 mm 41 mm

24
12
12
10

months
months
months
months

32 mm
36 mm
38 mm
26 mm

3 mm
2 mm
4 mm
7 mm

7 months 38 mm 3 mm

Significant
decrease in
postoperative
mouth
opening

90 min
45 min
80 min
120 min

85 min

M, male; F, female; preop., preoperative; postop., postoperative.

respectively, to the present day, the debate

regarding the ideal choice of treatment
still rages on.2,3 In 1990, Kaban et al.4
outlined a protocol for the management of
TMJ ankylosis that was then universally
followed; this was later modified by the
same author in 2009.5 A myriad of extraoral incisions and techniques have so far
been reported for gaining access to the
temporomandibular apparatus or the ankylotic mass, all of which have been a
challenge to the surgeon in terms of gaining adequate visibility, minimizing the
facial scar, negotiating the facial nerve
and auriculo-temporal nerves to prevent
injury, reducing intraoperative and postoperative haemorrhage, and the occurrence
of
occasional
anatomical
deformity of the ear, surgical infection,
and salivary fistula and sialocele.6 Many
authors have tried to circumvent these
complications by approaching the joint
transorally. However, in 2009, Ko et al.7
were the first and only authors to report
transoral access for the treatment of TMJ
ankylosis. In the current article the authors
share their experiences of transoral access
to TMJ ankylosis and describe the surgical
technique, which differs from that of Ko
et al. in a certain important aspect.
Patients and methods

A series of five patients with TMJ ankylosis, two unilateral and three bilateral,

underwent gap arthroplasty by transoral

approach between February 2012 and August 2013 (Table 1). The average age of
the patients at the time of surgery was 14.4
years and none of them were recurrent
cases. Two of the patients had Sawhneys8
type I ankylosis and three of them had type
II ankylosis. The average mouth opening
at the time of surgery was 8.6 mm, with
the lowest being 4 mm and the highest
14 mm. All patients had a history of trauma to the mandible, with two of them
reporting a history of prolonged maxillomandibular fixation. Follow-up ranged
from 7 to 24 months, with a mean follow-up of 13 months. No interpositioning
material or substance was used in any of
the cases. Physiotherapy and mouth opening exercises were started on day 1 postoperative and were performed with
increasing intensity towards day 7.
Patients were generally discharged on
the third postoperative day and were
reviewed once a week for the first month
and once a month for the rest of the followup period. Condylar reconstruction is generally contemplated after an ankylosisfree period of 1 year; this is achieved
using ramus distractors.
The inclusion criteria for patient selection were the following: (1) Sawhneys
classification types I, II, and III TMJ ankylosis (Table 2). (2) No gross medial
extension or involvement of the zygomatic
arch by the ankylotic mass, as evident on

three-dimensional computed tomography

(CT) scan. The anatomical outline of the
lower border of the zygomatic arch should
be delineable on sagittal CT images. (3)
Sigmoid notch should also be delineable
on CT images and should be free of ankylotic mass. (4) Non-recurrent cases (primary ankylosis cases).
Surgical technique

Nasotracheal intubation was done to administer anaesthesia to all five patients

using the blind awake technique. Following this, the incision site was infiltrated
with 10 ml of lignocaine and adrenaline
(1:200,000 concentrations). With adequate retraction, a mucosal incision was
made along the external oblique ridge
beginning from the mandibular first molar,
posteriorly along the anterior border of the
ramus. A mucoperiosteal flap was raised
on the lateral and medial surface of the
mandible down to the angle region and
superiorly until the inserting fibres of the
temporalis muscle were visualized. These
were incised and retracted upwards with
the aid of a forked ramus retractor, almost
to the tip of the coronoid. A malleable
retractor was then placed at the inner
aspect of the ramus to protect the internal
maxillary artery that lies immediately
deep to the condylar neck and the channel
retractor was moved upwards for
better access to the ankylosed area. An

Table 2. Bony ankylosis (TMJ ankylosis): Sawhney classification, 1986.

Condylar head is flattened or deformed in close approximation to the upper joint space. Dense fibrous adhesion is present within.
Type I
Restricted motion is due to fibrosis in and around the joint.
Type II
Flattened condyle in close approximation to the glenoid fossa; bony fusion of the outer aspect of the articular surface either
anteriorly or posteriorly and limited to a small area.
Type III
Ankylosis usually results from a medially displaced fracture dislocation of the condyle with bone bridging the ramus of the
mandible to the zygomatic arch. The atrophic condylar head is either free or fused to the medial aspect of the superior portion of the
ramus.
Type IV
A wider bony block bridges the mandibular ramus and zygomatic arch, extending and obliterating the upper joint space and
completely replacing the architecture of the joint.
TMJ, temporomandibular joint.

1470

Rajan et al.
Limitations of transoral access

Fig. 1. Sagittal view of coronoidectomy. The

orientation of the surgical bur and medial and
lateral protectors can be appreciated. (a) Copper malleable retractor on the medial aspect.
(b) Orientation of the surgical bur during
osteotomy in the sagittal plane. (c) Channel
retractor on the lateral aspect.

osteotomy was performed at the base of

the coronoid process, running obliquely
upwards towards the sigmoid notch
(Fig. 1). The osteotomy was completed
with the aid of osteotomes and the coronoid was retrieved transorally after
detaching the remaining fibres of the temporalis.
Once the coronoid was out, an attempt
was made to increase the mouth opening
with the aid of a Heister mouth opener. In
bilateral ankylosis cases and in cases
where there was persisting resistance to
an improvement in mouth opening, the
same was attempted after completing the
coronoidectomy on both sides/the contralateral side. It was observed that mouth
opening improved by an average of 3 mm
after unilateral coronoidectomy and 5 mm
after bilateral resections. A mouth prop
was placed inter-occlusally on the contralateral side to maintain the mouth opening.
The dissection was carried out superiorly
towards the zygomatic arch, and once it
was identified, a periosteal incision was
made at the inferior border and a subperiosteal dissection was carried out along the
arch posteriorly to trace the anterior and
superior extent of the ankylotic mass and
glenoid fossa. Once the superior extent of
the ankylotic mass was delineated, an
osteotomy was initiated at about 1.5 cm
below the superior-most extent of the
mass. This osteotomy was completed to
separate the ankylotic mass first from the
distal mandible, and then the mass was
released from its superior attachment to
the cranial base using an osteotome and
surgical bur, as required. During this entire
process, the medial vital structures such as
the internal maxillary artery (IMA) and
inferior alveolar neurovascular bundle
(IANB) were protected from injury using
a malleable copper retractor, which was
moulded to fit the shape of the ankylotic

Fig. 2. Orientation of the instruments while

performing the inferior cut, in sagittal view.
(a) Copper malleable retractor on the medial
aspect. (b) Orientation of the surgical bur
during osteotomy in the sagittal plane. (c)
Channel retractor on the lateral aspect.

mass. On the lateral aspect, a channel

retractor engaging the posterior border
was used. The channel retractor groove
can carry a fibre optic light source, if
available, to enhance visibility at the surgical site (Figs 2 and 3). The entire ankylotic mass was removed in one piece or in
a piece-meal fashion depending on the
medial extent of the exuberant mass. In
bilateral cases, the same procedure was
repeated on the opposite side. Although no
interpositional material was used in any of
our cases, a locally available buccal pad of
fat or the fibres of the temporalis muscle
detached from the tip of the coronoid
process can be upturned for use as interpositional material. After release, the
mandible was vigorously opened and mobilized to release any leftover fibrous
union. Postoperative physiotherapy was
started on the first postoperative day, with
gradually increasing intensity towards the
end of the first week.

Fig. 3. Orientation of the instruments while

performing the superior cut, in sagittal view.
(a) Copper malleable retractor on the medial
aspect. (c) Channel retractor on the lateral
aspect. (d) Orientation of the osteotome for
the superior cut in the sagittal plane.

There are certain limitations related to

case selection and technical expertise.
This access is not suitable for cases with
exuberant ankylotic masses that have distorted the regional anatomical landmarks,
as in Sawhneys type IV TMJ ankylosis,
patients with associated conditions that
limit mouth opening, such as oral submucous fibrosis (quite rampant in the Indian
subcontinent), or patients with associated
craniofacial syndromes that could cause
an aberrant anatomy. The risk of injury to
the IMA or IANB and other vital structures is high when surrounding tissues are
not well retracted and protected during
resection of the ankylotic mass. The technique is also not suitable for previously
operated cases with recurrence.
Results

Representative images of a patient undergoing this technique are shown in Fig. 4.

The targeted minimum mouth opening
at the end of surgery on table was 35 mm
and this was achieved in all patients except
one (patient 4). The mouth opening
achieved ranged from 33.6 mm to
42 mm, with a mean mouth opening of
37.9 mm. All of the patients presented a
slight decrease in mouth opening during
follow-up, but none of the patients had any
recurrence or significant decrease in postoperative mouth opening. One patient (patient 4) had a decrease in mouth opening of
7 mm at the 2-month follow-up, which
was the maximum decrease among all
patients. Mouth opening in this patient
was subsequently maintained with active
physiotherapy. The mean decrease in
mouth opening at the last follow-up as
compared to that achieved at the time of
surgery was 3.8 mm.
Apart from the one patient showing a
significant decrease in mouth opening,
none of the patients experienced any significant intraoperative or postoperative
complications. The most frequent intraoperative complication noted was excessive bleeding, which was usually
controlled using local measures such as
gauze packing. The superior-most extent
of the ankylotic mass was traceable in all
patients using this technique, irrespective
of the size and extent of the mass. The
duration of surgery ranged from 45 min to
120 min, with a mean duration of 84 min.
Discussion

The ultimate goal in the treatment of TMJ

ankylosis is to restore mouth opening to at

Transoral gap arthroplasty for TMJ ankylosis

Fig. 4. (A) Preoperative orthopantomogram of left unilateral ankylosis. (B) Preoperative 3D

reconstructed image of left unilateral ankylosis. (C) Intraoperative photograph of transoral
access and gap arthroplasty. (D) Postoperative orthopantomogram of the same patient at followup.

least 35 mm, prevent any further recurrence, and to restore as near normal ramus
height as possible either by reconstruction
or by distraction osteogenesis. To realize
these goals, of foremost importance is the
attainment of good access to the joint area,
which is necessary for adequate resection
of the ankylotic mass. The variety of
incisions and techniques described in published reports on approaches to the condyle9 reflects the complexity of the
anatomy of this region and the importance
of preservation of the vital structures in the
pathway.
The classical pre-auricular approach described by Blair10 and by Dingman and
Grabb,11 and the modified versions of AlKayat and Bramley12 and Popowich and
Crane13 carry the risk of injury to the
peripheral branches of the facial nerve
and an unsightly scar on the face. The
post-auricular incision described by Alexander and James14 gives the best cosmetic
results, as the incision is hidden in the
post-auricular crease. Injuries to the facial
nerve are minimal with this approach, but
in cases of massive ankylosis, it may be
difficult to reach the anterior extent of the
ankylotic mass. Further, this approach
may result in residual ear deformity or
auricular stenosis. Bansal et al.6 compared
the pre-auricular approach with the postauricular approach in 30 joints with TMJ
ankylosis. They outlined the many benefits of the post-auricular approach, but also
suggested that it may lead to more intraoperative haemorrhage and a prolonged

time to expose the joint. Politi et al.15

proposed a surgical technique called the
deep subfascial approach, in which they
claimed that transient and permanent facial nerve injury were prevented by developing an additional protective fascial layer
when the dissection was performed deep
to the deep temporalis fascia. The bicoronal flap approach described by Pogrel
et al.16 for bilateral ankylosis cases carries
no special advantage over two separate
bilateral pre-auricular incisions with temporal extensions. In the view of the authors
of the current article, this technique carries
the additional burden of more blood loss
and a longer duration, and has no advantage in terms of wider exposure and access
to the ankylosed mass as compared to the
conventional pre-auricular approach.
Although many authors in the past have
described an intraoral approach to the
condyles to treat the various problems
related to these,17,18 it was Ko et al.7
who first published this technique to treat
TMJ ankylosis. The authors of the current
article observed similar advantages and
disadvantages with their technique as described by Ko et al. The advantages include the absence of a facial scar, less
possibility of injuring the facial nerve
and the auriculo-temporal nerves, no sialocele, simultaneous coronoidectomy via
the same incision, and the ability to protect
the internal maxillary artery by placing a
retractor on the medial surface of the
ramus and thus reducing the chance of
haemorrhage. The disadvantages with this

1471

technique, such as a limited surgical field,

the requirement of a good sense of orientation, and the limitations regarding the
selection of interpositional material, are
also agreed upon. However, the surgical
technique presented here differs from that
of Ko et al., in which they advocate retaining the superior part of the ankylotic mass
without any attempt at removing it to
prevent the possible risk of middle cranial
fossa perforation. Salins3 clearly stated the
importance of complete excision of the
ankylotic mass to prevent reankylosis.
He reported that partial excision of the
ankylotic bone often results in reorganization of the entire mass and complete encapsulation of the interpositioning
materials. The bridging ankylotic mass
continues to grow without any signs of
remodelling and is augmented on the medial side by a tough fibrous scar that makes
the second intervention even more challenging. Similarly Kaban et al.4 and Raveh
et al.19 emphasized the need for complete
excision of the ankylotic mass to prevent
reankylosis. The technique of complete
removal of the ankylotic mass presented
in this current article relies on tracing the
superior-most extent of the mass at its
junction with the cranial base using the
inferior border of the zygomatic arch as a
key anatomical landmark.
In one of the largest case series on TMJ
ankylosis published in this journal in 2010
by Elgazzar et al.,20 the authors retrospectively evaluated and compared the outcome of over 100 cases treated by them
with gap arthroplasty, interpositional
arthroplasty, or reconstruction arthroplasty. The authors outlined various
options available for interpositioning
and stated that the interpositioning arthroplasty is an option when there is a high
chance of reankylosis or in the presence of
large bony ankylosis. However they did
not specifically classify the type of TMJ
ankylosis for which they used interpositioning material or a reconstructive arthroplasty. The outcome was most favourable
when the joint was reconstructed with
distraction osteogenesis plus interpositioning with a temporo myofascial flap.
Two out of 11 cases treated by gap arthroplasty showed signs of recurrence by the
third postoperative month, which
prompted the authors to perform second
surgery. However a similar rate of recurrence (2%) was also seen in reconstructed
TMJ ankylosis in this case series.
In the current study, gap arthroplasty
was performed with no interpositioning
material, not because it is technically more
challenging by transoral approach, but
because the authors believe aggressive

1472

Rajan et al.

postoperative physiotherapy and proper

counselling of the patient prior to surgery
to be the most important factors in preventing reankylosis. As mentioned earlier,
the indication for this technique is the
presence of a minimal to moderate sized
ankylotic mass (Sawhneys classification
types I, II, and III) and not massive ankylosis, which poses a risk of postoperative
recurrence. The authors views on avoiding interpositioning material are shared by
Katsnelson et al.2 who published a systematic review and meta-analysis in 2012.
Similarly, Choudhury et al.,21 in their
series of 50 cases of TMJ ankylosis, emphasized the crucial role of postoperative
physiotherapy over interpositioning.
Danda et al.,22 in a comparative study of
gap arthroplasty vs. interposition arthroplasty in 16 cases, categorically stated that
there was no statistically significant difference in outcome between the two procedures and stressed the importance of
patient cooperation, active physiotherapy,
and regular follow-up. However, ardent
believers in interpositioning can still use
a locally available buccal pad of fat or the
detached temporalis muscle fibres from
the coronoid tip to fill the gap.
The average follow-up period of 13
months in the current study may not be
adequate to rule out the possibility of
reankylosis. Even though a minimum 5
years of follow-up to rule out any recurrences would be ideal, the authors believe
that unlike malignancy in TMJ ankylosis,
the possibility of reankylosis is generally
evident within 6 months, as seen in the
study by Elgazzar et al.20 In addition,
stable mouth opening and satisfactory
mandibular movements beyond 1 year
can be taken as indicators of stable results.
The value of endoscopic techniques in
the transoral approach to TMJ ankylosis is
irrefutable, as described by Sembronio
et al.23 It is easy to check the medial aspect
of the resection, and intraoral endoscopic
guidance may be useful to safely remove
the ankylotic mass and anchor the temporalis muscle and fascia flap more accurately, reducing the risk of reankylosis.
Although the transoral approach cannot
be employed in every case of ankylosis,
especially in massive and recurrent cases,
the option of using this approach should
always be borne in mind whenever possible and an endoscope used when available
to improve the accuracy.
Funding

None.

Competing interests

None declared.
Ethical approval

Institutional ethics board clearance was

obtained (SVSIRB/12-03/2012).
Patient consent

Acquired.
Acknowledgements. Ram Basany for his
contribution of artistic work of diagrams.
Srinivas Ganti and Zuber Vaja for their
help with typing and compilation work.

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Address:
Abhinand Potturi
Department of Oral and Maxillofacial
Surgery
SVS Institute of Dental Sciences
Mahaboobnagar
Andhra Pradesh 509002
India
Tel: +91 9949501474
E-mail: abhinand.omfs@gmail.com