Temporomandibular Surgery

TMJ Ankylosis occurs when the mobile lower jaw fuses with the skull and prevents the patient from opening his mouth. This leads to an inability to chew food, poor oral hygiene and facial deformity.

This 34 year old man came to us with a complete ankylosis of his Left Temporomandibular Joint (TMJ) with only 1-2 mm mouth opening. He has had at least 3 attempts on relieving the TMJ ankylosis done elsewhere in the past. All the attempts had failed and reankylosis had occurred. CT scans now showed the callus to extend medially. There were two options available to us: One was to release the ankylosis at the condylar level (which would be the first choice in “fresh” cases or alternatively one could do an Esmarch’s procedure– whereby we would create a gap at the angle region and mobilize the medial pterygoid and massetter muscles and suture them together thus creating a barrier to re-ankylosis. Numerous studies have shown the patients who are prone to TMJ ankylosis have a very high osteogenic potential at the condylar region and are thus very highly prone to re-ankylosis. Dr.Esmarch proposed to leave the condyle region alone and do a gap arthroplasty at the angle and interpose muscle between the bony ends to prevent re-ankylosis. This procedure was named after its inventor as Esmarch’s procedure.

Under GA, (retrograde nasal intubation confirmed with an video bronchoscope, a submandibular incision was made and the gap arthroplasty was done at the angle region. Contralateral Coronoidectomy was also done to improve mouth opening further. On table the mouth opening was around 35 mm as measured with a caliper. Postoperatively he healed up well and is maintaining his mouth opening currently at 35 mm. He has been strictly advised to do his jaw exercises on a daily basis and has been placed on a normal diet. In fact we encourage him to eat hard food to create a nonunion. He is now due for orthodontics and dental reconstruction followed by orthognathic surgery to correct the residual facial deformity

The other main issue with TMJ ankylosis patients is the difficulty in intubating these patients as the anatomy is distorted due to the deformity and there is also no mouth opening. An experienced difficult airway team is vital to overcome these issues. At our centre we have various options available ranging up from tracheostomy, fibreoptic intubation, blind nasal or retrograde intubation.

Pre-op: Maximal mouth opening ( approx 1-2mm) with large ankylotic mass seen in L condylar region along with elongated R coronoid process

Post-op: Maximal mouth opening( approx 34 mm) with Esmarch’s procedure and contralateral Coronoidectomy done.

Retrograde intubation in progress...

Videobronchoscopy confirming ET tube is in the trachea

Gap created at angle region of mandible and muscle superimposed

Mouth opening on table approx 34-35 mm

This 22 year old young man had had multiple attempts at releasing his TMJ ankylosis including costochondral grafts, etc done at centres elsewhere– all had failed. We then planned for him to have Osteodistraction in the first phase followed by Ankylosis release.

Osteodistraction is a technique of slow bone distraction invented by Dr.Ilizarov-a russian orthopedic surgeon. Clinically it is used in situations where there is very little bone stock , where standard osteotomy procedures cannot be done. The bone to be distracted is cut and an osteodistractor is placed between the bony cuts; callus allowed to form and then a slow distraction of 1mm per day is done to allow the callus to grow. Faster movement more than 1 mm will not allow the callus to grow and nonunion will occur; Slower movement less than 1mm will cause premature consolidation.

Osteodistraction consists of 4 sequential phases:1).Osteotomy-bony cuts between segments and osteodistractor placed 2) Latency of 3-5 days to allow the callus to form 3) Distraction of 1 mm per day to allow the bone to grow 4)Consolidation and remodeling– allows the distracted callus to form into normal bone. This can be done in one plane; two planes or 3 planes ( X,Y and Z axis). Indian manufactured osteodistractors usually allow only uniplanar or biplanar Osteodistraction. Multiplanar osteodistractors are invariably imported from Germany and extremely expensive but results are excellent.

We did a fibreoptic confirmation and then placed bilateral Leibinger Multiplanar osteodistractors. After a latency phase of 5 days we started Osteodistraction at the rate of 1 mm per day. Each axis ( X,Y and Z) was addressed separately and a movement of over 43mm was done finally. After consolidation for 2.5 months the osteodistractors were removed. The bone has grown very well and amazingly the mouth opening also increased simultaneously. We suspect this is due to a leverage effect. Thus the patient will now only need a genioplasty (a much simpler procedure with good results) and not an TMJ Ankylosis release procedure ( a more complicated procedure). Multiplanar distraction was the best way forward for this patient as it allowed maximum control for this patient albeit being a bit costly.

The patient was extremely pleased with the results– he had never opened his mouth since he was 2 years old and for the first time in 20 years he was able to take a normal diet and look normal. He had dropped out from school due to constant teasing and has now enrolled in a re-education programme- a clear instance of keeping up with our motto of “Saving faces and Changing lives”. The happiness and confidence that we see in these patients post-operatively makes all this hard work worthwhile

Pre-op: TMJ Ankylosis patient with maximum mouth opening of only 1-2mm despite numerous attempts at TMJ ankylosis release.

Post-op: Multiplanar Leibinger osteodistractors placed and Osteodistraction done– mouth opening has greatly increased. The distractions will be removed after 2 months completely.

Leibinger multiplaner osteodistractors(German)

Fibreoptic intubation being done by the anesthesia team.