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Temporomandibular joint ankylosis commonly occurs as a result of trauma to the face resulting in fusion of the temporal bone to condyle of the mandible .Immediate and appropriate care of facial fractures can minimise the risk of development of ankylosis. We report a case of TMJ ankylosis in a 65 year old lady with complaint of inability to open the mouth since 44 years . The lack of appropriate treatment at the time of trauma led to TMJ ankylosis and its sequale for 44 years. The ankylosis was surgically managed followed by aggressive physiotherapy. Surgeries in geriatric patient need to outweigh benefit over risk. The article describes challenges posed in rehabilitation of this patient

Kamath, Abhay Taranath

Bhagania, Manish

Pai, Deepika

Singh, Satpal

Amit, Dr

Pradeep, Ambika

Acta Medica Scientia 01 [01] (2014)                                                                                     E-ISSN: 2454-3594 
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© ASD Publisher All rights reserved.                                                                                                                                                                                                                     1 
Case Report 
Challenges in Rehabilitation of long standing ankylosis of temporo mandibular joint: 
A case report of a 65 years old lady 
 
Abhay Taranath, Manish Bhagania, Deepika Pai*, Satpal Singh, Amit and Ambika Pradeep 
 
Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal 576104 
 
*Corresponding Author 
Dr. Deepika Pai 
Associate Professor 
Department of Pedodontics 
Manipal College of Dental Sciences, Manipal.576104 
E-mail: Deepikapai0479@gmail.com  
 
Keywords: 
Temporomandibular joint , 
Ankylosis,  
Rehabilitation, 
Mouthopening,  
Surgical management. 
 
1. Introduction 
Temporomandibular (TMJ) ankylosis is an intracapsular union 
of the disc-condyle complex to the temporal articular surface that 
restricts mandibular movements, including the fibrous adhesions or bony 
fusion between condyle, disc, glenoid fossa, and eminence [1]. The most 
common causes for TMJ ankylosis are falls, road traffic accidents and 
sport injuries, including play accidents. TMJ ankylosis can also be caused 
by local or systemic infection such as otitis media and mastoiditis, 
tuberculosis, scarlet fever and gonorrhea, (10-49%), Paget’s disease, 
pseudohypoparatroidism and psoriasis, sickle cell anemia, fibrodysplasia 
ossificans progressiva. MJ ankylosis is commonly acquired 
developmental disorder of face in children. With most patients (70.0%) 
being in the 10-15 years’ age group (mean age was 11.1 years ± 3.34) 
[2,3]. Here we report a case of 65 year old lady who sustained trauma at 
the age of 21 years of age, the outcome of such injury and challenges 
faced in rehabilitation of this patient. 
 
2. Case report 
We report a case of a 65 year old woman who presented with a 
history of at the age 21 years following which the mouth opening 
gradually reduced and became 0 within months. Patient didn’t seek any 
treatment at that time because of her financial status and now she was 
bought to us by her son for providing treatment. Since then she has been 
unable to open her mouth for 44 years. She had difficulty in speech and 
was on restricted diet for long years. On examination there was no facial 
asymmetry or growth deficiency. Old scar was present on chin region. 
There was nil mouth opening and no condylar movements were palpable. 
(Figure 1).  
Figure 1. Mouth opening and condylar movements 
 
There was a bony hard mass palpable in left TMJ region. 
Intraorally upper and lower anterior teeth were missing with poor oral 
hygiene. The Missing upper anteriors were helpful in taking liquid and 
semisolid food. OPG, PA mandible and contrast enhanced CT scan with 3-
D reconstruction was done which revealed pure bony ankylosis of left 
TMJ, fibrous ankylosis with deformed right condyle due to disuse, 
bilateral elongated coronoid processes (Figure 2&3). 
 
Figure 2. CT scan with 3-D reconstruction 
 
 
Figure 3. CT scan with 3-D reconstruction 
 
Her systemic evaluation revealed she was fit for surgical 
intervention under general anaesthesia. She was taken up for bilateral 
gap arthroplasty with temporalis muscle interpositioning. Securing the 
airway was the biggest challenge in this case as there was no possibility 
of direct laryngoscopy because of nil mouth opening, therefore awake 
Abstract 
 
Temporomandibular joint ankylosis commonly occurs as a result of trauma to the 
face resulting in fusion of the temporal bone to condyle of the mandible .Immediate and 
appropriate care of facial fractures can minimise the risk of development of ankylosis. We 
report a case of TMJ ankylosis in a 65 year old lady with complaint of inability to open the 
mouth since 44 years. The lack of appropriate treatment at the time of trauma led to TMJ 
ankylosis and its sequale for 44 years. The ankylosis was surgically managed followed by 
aggressive physiotherapy. Surgeries in geriatric patient need to outweigh benefit over risk. 
The article describes challenges posed in rehabilitation of this patient. 
 
Taranath et al/ Rehabilitation of longstanding ankylosis of temporo -mandibular joint in a 65 year old lady: A management quandary. 
 
© ASD Publisher All rights reserved.                                                                                                                                                                                                                         2 
fiberoptic nasotracheal intubation was carried out for securing the 
airway. The left TMJ ankylosis was approached first through Alkayat-
Bramley approach. A preauricular incision with question mark shaped 
temporal extension was given and skin, subcutaneous tissue and 
temporoparietal fascia were incised sharpely to reach the glistening 
white superficial layer of deep temporal fascia. Blunt dissection was done 
on this fascia to expose the TMJ and later temporalis muscle for 
interpositioning. An imaginary line drawn from upper point of tragus to a 
point 2cm above the fronto-zygomatic suture was the limit of anterior 
direction because anterior to this line the frontal and temporal branch of 
facial nerves crosses the Zygomatic arch in the same plane. An incision at 
45 degree to the zygomatic arch and 2 cm above it was given on 
superficial layer of deep temporal fascia and dissection was carried 
inferiorly deep to this layer to reach the Zygomatic arch.  
Periosteal incision was given on superior border of arch and 
entire width of arch along with ankylotic mass was exposed. Superior 
osteotomy was kept at the level of inferior border of arch and inferior 
osteotomy was marked at 1.5 cm below the superior cut. The entire 
ankylotic mass in its entire later-medial width and with elongated 
coronoid attached anteriorly was removed in toto. At this stage only 5 
mm of mouth opening was achieved. The right side also was exposed in 
the same manner as left (Following Kaban, Parrot and Fissure protocol). 
The right condyle was found to be deformed, osteoporotic with fibrous 
adhesion obliterating the joint space. Right coronoid was also elongated 
with atrophic temporalis muscle. Right side condylectomy and 
coronoidectomy was performed and this time a mouth opening of 33 mm 
was achieved.  
After achieving satisfactory mouth opening the native disc was 
secured with sutures in right joint space to act as interpositional 
material. On left side 5cm long and 2 cm wide temporalis muscle flap was 
elevated from posterior fibers interposed in the joint space and secured 
by suturing it to the remnants of lateral pterygoid on the medial aspect of 
remaining ramus. Vacuum drains were secured in bilateral surgical sites 
and layered closure of incision was done. Patient sustained the procedure 
well, an immediate postoperative mouth opening of 34 mm was achieved 
(Figure 4) and was kept hospitalized for 10 days to provide postoperative 
care, antibiotics, analgesics and nutrition. Daily physiotherapy in form of 
aggressive mouth opening exercise with use of acrylic mouth opening 
devices (Figure 5), guiding elastic therapy for mandibular closure and 
ultrasound therapy for muscle relaxation and pain relief were all started 
from third postoperative day.   
 
Figure  4. Postoperative mouth opening 
 
 
Figure 5. Acrylic mouth opening devices 
 
 
 
3. Discussion 
As a result of inability in opening the mouth the patient had 
poor oral hygiene and had not enjoyed a meal for a long time of 44years. 
This patient remained  un operated for many years, this could have been 
possible a result of a  poor appreciation of the role of surgery in the 
management of TMJ ankylosis by the dentist who managed the initial 
trauma at 21 years of her age or lack of proper referral to centres 
delivering  such surgical care. However this case demonstrates the 
evidence of fate of untreated cases of facial injuries resulting in 
Temporomandibular joint ankylosis. TMJ ankylosis results in trismus or 
inability to open the mouth .This can not only cause difficulty in intake of 
food and thus affects general well being but also cause difficulty in speech 
and maintenance of oral hygiene. This affects the personality of the 
individual and reflects greatly on one’s social life. [4,5] 
In today world the infectious reason for TMJ ankylosis has 
become nearly obsolete but one cannot rule out the probability of 
sustaining trauma to face. Particularly any trauma to the chin translates 
the impact to the condyles. [6,7]It is hypothesized that the formation of 
an intra-articular hematoma with subsequent scarring and new bone 
formation is the common precipitant. This new bone formed causes 
hypomobility and is termed as fibrous ankylosis if left untreated over 
timea fibrous ankylosis transformsinto bony ankylosis resulting in total 
closure of mouth[8]. 
In this case the Kaban’s protocol was followed in managing the 
bilateral TMJ ankylosis. The temporalis myofacial flap was interposed to 
prevent reankylosis.[9]Active physiotherapy and guarded watchful 
follow-up in intial stages is minimal invasive modality of management as 
long as any evidence of bony union is not seen. But immediate surgery 
can halt progression of a fibrous ankylosis to total joint ankylosis and its 
sequalae. 
 
4. Conclusion  
In Geriatric patient the systemic conditions like hypertension, 
diabetes and arthritis especially in women are commonly known factors 
that contraindicate a surgical option. While surgery is often considered as 
the last option in cases of TMJ ankylosis, surgery is the definitive 
treatment option. However risk should outweigh the benefits of surgical 
intervention. Surgical management in TMJ ankylosis results in adequate 
mouth opening but active and vigorous physiotherapy in both immediate 
and later post operative days can only prevent reankylosis. 
 
References 
[1] Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, et al. Preservation of disc 
for treatment of traumatic temporomandibular joint ankylosis. J Oral 
Maxillofac Surg 2005;63(7):897-902, 
[2] Valentini V, Vetrano S,  Agrillo A, Torroni A, Fabiani F, Iannetti G. 
Surgical treatment of TMJ ankylosis: our experience (60 cases). J 
Craniofac Surg 2002;13: 59–67. 
[3] Miller GA, Page HL Jr, Grifith CR. Temporomandibular Ankylosis: 
Review of literature and report of 2 cases of bilateral involvemenet,J 
Oral Surg 1975;33(10):792-803. 
[4] Chidzonga MM. Temporomandibular joint ankylosis: review of thirty-
two cases. Br J Oral Maxillofac Surg 1999; 37(2):123-6. 
[5] Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap 
arthroplasty in temporomandibular joint ankylosis: a report of 50 
cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endodv 1999; 
87(2):166-9. 
[6] Shah AA. Silastics as interpositional gap arthroplasty in TMJ 
ankylosis. Ann K E Med Coll 2004; 10: 84-5. 
[7] Vinay Kumar Gupta, Divya Mehrotra, Seema Malhotra, Sandeep 
Kumar, Girdhar Gopal Agarwal, and Uma Shanker Pal.An 
epidemiological study of temporomandibular joint ankylosis.,Nnatl J 
O M S 2012; 3(1):25–30. 
[8] Marianowski R, Martins CC, Potard G, et al. Mandibular fractures in 
children—long term results. Int J Pediatr Otorhinolaryngol 
2003;67:25–30. 
[9] Kaban LB,Bouchard C,Troulis MJ.A protocol for management of 
temporomandibular joint ankylosis in children.J Oral and Maxillofac 
Surg 2009;67(9):1966-78. 
 


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