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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 45-49

Recurrence of temporomandibular joint ankylosis: Fascia lata a good alternative. A case report


Department of Oral and Maxillofacial Surgery, Maharashtra Institute of Dental Science and Research Center, Vishwanathpuram, Latur, Maharashtra, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Syed A Mohiuddin
Department of Oral and Maxillofacial Surgery, Maharashtra Institute of Dental Science and Research Center, Vishwanathpuram, Ambajogai Road, Latur -. 413 512, Maharshtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-8574.202056

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  Abstract 

Recurrence of temporomandibular joint (TMJ) ankylosis is a known complication. Studies have contributed to the various treatment options in recurrent ankylosis. The causes of reankylosis of TMJ, to our experience is due to inadequate gap arthroplasty, insufficient interpositional material, adhesion and elongation of the coronoid process. It has been reported in the literature that the incidence varies with choice of treatment modality, severity of ankylosis, site (unilateral/bilateral), and the surgeons skill. The patient's compliance to the post-treatment physiotherapy is the main reason for reankylosis. Here, we present a case of left TMJ reankylosis in a 22-year-old female, previously treated by interpositional gap arthroplasty using temporalis muscle, and had developed recurrence after ˜ 1 year of treatment, then it was successfully treated with gap arthroplasty using fascia lata as interpositional material.

Keywords: fascia lata, interpositional gap arthroplasty, reankylosis, temporalis muscle


How to cite this article:
Mohiuddin SA, Badal S, Doiphode A, Chougule S. Recurrence of temporomandibular joint ankylosis: Fascia lata a good alternative. A case report. Tanta Dent J 2017;14:45-9

How to cite this URL:
Mohiuddin SA, Badal S, Doiphode A, Chougule S. Recurrence of temporomandibular joint ankylosis: Fascia lata a good alternative. A case report. Tanta Dent J [serial online] 2017 [cited 2021 Oct 19];14:45-9. Available from: http://www.tmj.eg.net/text.asp?2017/14/1/45/202056


  Introduction Top


Temporomandibular joint (TMJ) ankylosis is defined as 'a restriction of movements due to intracapsular fibrous adhesion, fibrous changes in capsular ligaments (fibrous ankylosis) and osseous mass formation resulting in the fusion of the articular components (osseous ankylosis)' [1].

TMJ is a unique joint and classified as ginglimo-diarthrodial synovial joint and its function are governed by muscle, ligaments, joint architecture and teeth. Most importantly, are the teeth and occlusion where other joints are not influenced by structure like teeth and its function. Different types of ankylosis described in literature include intra-articular (true), extra-articular (false), bony, fibrous, complete and incomplete ankylosis. TMJ ankylosis is more commonly associated with trauma (13–100%), local or systemic infection (10–40%), or systemic diseases (10%), such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis [2].

The most common cause of TMJ ankylosis being trauma, followed by infection. The different treatment modalities for TMJ ankylosis, are gap arthroplasty, interpositional arthroplasty, joint prostheses and distraction osteogenesis, etc. The causes of failure of the surgical treatment are well documented in literature like inadequate gap arthroplasty, insufficient interpositional material, fibrous tissue adhesion, elongation of the coronoid process, muscle shrinkage and fibrosis, lack of sufficient bulk of the fascia, fibrosis and calcification of the auricular cartilage, foreign body giant cell reaction specially with alloplastic implants [3],[4],[5],[6].

In our case, the reason for loss of temporalis flap and reankylosis could not be confirmed. We opted for fascia lata and it proved to be a good alternative because of its thick sheets of inert collagen, and resistant to resorption [7].

Follow-up for 3 years without complaints and recurrence proves the versatility of this material. This can be one of the choices as interpositional material for recurrence of TMJ ankylosis.


  Case Report Top


A 22-year-old female patient reported to the Department of Oral and Maxillofacial Surgery with chief complaint of restricted mouth opening since last 3 years.

The patient gave a history of fall, 4 years back, due to which she had trauma to the left side of the face. Following which she experienced difficulty in jaw movements with gradual limitations in mouth opening. Due to limited mouth opening patient not only had difficulty in chewing but also in maintaining oral hygiene.

Approximately 1 year later, all her jaw movements were completely lost. She counsulted a specialist for this complaint and was operated for the same. After obtaining a proper history, it was revealed that she was operated for the TMJ bony ankylosis of the left side by interpositional arthroplasty using temporalis muscle flap 1 year before. All her jaw movements were restored following an operation. Then 8 months later, she again experienced a gradual decrease in her mouth opening. The patient reported to our department with the maximal mouth opening of less than one finger.

Medical history was insignificant. Clinical examination revealed facial asymmetry with flattening on the right side of the face and a scar over left preauricular region was noticed. The mandible was deviated towards left side. All her mandibular movements were restricted markedly ([Figure 1]).
Figure 1: Preoperative.

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On palpation, no abnormality was detected in the muscle of mastication. The intraoral examination revealed poor oral hygiene with maximal mouth opening of 8 mm ([Figure 2]). Panoramic view showed absence of well defined condylar morphology, the condyle was replaced by an osseous mass at the left TMJ extending from the articular eminence to the posterior lamina, about 1.5 cm × 1.5 cm in dimension ([Figure 3]). Clinical and radiographic findings confirmed bony reankylosis and planned for interposition arthroplasty with fascia lata as an interpositional material.
Figure 2: Preoperative mouth opening.

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Figure 3: Orthopantomogram.

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The ethical committee of the institute was approached and research approval was obtained. The surgical procedure was completely explained and a written consent was taken from the patient for the research and the surgical procedure under general anesthesia. Alkayat Bramley incision used for access ([Figure 4]). The flap was reflected and ankylotic mass was exposed ([Figure 5]). This ankylotic mass was resected and a gap of about 1.5 cm was created. Intraoperative mouth opening of 40 mm was achieved with the free movements of the mandible, which were assessed manually ([Figure 6]). Then fascia lata was harvested from left thigh and secured between the gap created, by suturing to the adjacent tissues ([Figure 7]). The wound was closed layer wise and pressure dressing was given. Physiotherapy was started on the next day of the surgery and advised to continue for life time. The patient was followed up for every 3 months. The maximal mouth opening achieved during this period was 40 mm till the last visit at the end of 3 years ([Figure 8]). All the excursive movements of the mandible were restored successfully.
Figure 4: Surgical incision.

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Figure 5: Surgical exposure.

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Figure 6: Intraoperative mouth opening.

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Figure 7: Harvesting of fascia lata.

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Figure 8: Postoperative mouth opening.

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  Discussion Top


The surgical treatment is mandatory for true bony ankylosis as well as reankylosis of the TMJ. There are four basic surgical procedures that have been reported in literature for TMJ ankylosis gap arthroplasty, interpositional arthroplasty, joint reconstruction and distraction osteogenesis. The disadvantages of gap arthroplasty are pain, crepitus, degenerative changes, limited movements, and reankylosis [8]. This lead to the emergence of interpositional arthroplasty as a treatment choice for most of the surgeons.

The rationale behind inserting an interpositional material is to create a partition among the apposing surfaces that are created after removal of ankylotic bony mass, thus preventing fibrous adhesion across the gap [9]. To prevent fibrous adhesion a wide, stable interposition material is required to completely cover the exposed medial surface of the TMJ [10].

Interpositional arthroplasty with various materials have been advocated in the literature, that are interposed between the resected bone surface and articular fossa at the base of the skull. These materials include both biological and non biological ones. The biological autogenous material recommended are full thickness skin, dermis, fascia, auricular cartilage, fat, fascia lata, temporalis muscle, etc., [7],[10]. Alloplastic material like methyl methacrylate [11],[12], though cost effective and less time consuming, present the risk of foreign body reaction and hypersensitivity.

The pedicled autologous graft like temporalis muscle, temporalis flap, and temporalis myofascial flap may undergo atrophy and shrinkage due to compromised blood supply [13]. The temporalis muscle is the most widely used among interpositional material due to its ease of usage, dependable blood supply, proximity to temporal joint, good functional results, minimal risk of facial paralysis, successful clinical results and minimal complications [10].

The complication reported with temporalis muscle flap were, persistence of postoperative pain [14] and reankylosis which could be prevented by rigorous, insensitive, and aggressive postoperative physiotherapy [15].

The treatment option documented by Balaji [10] to provide complete coverage of the resected bone surfaces by anchoring the broad temporalis flap to the medial surfaces of mandible can minimize flap shrinkage and may establish bipedicle blood supply. This can also reduce postoperative pain and eliminate reankylosis [10].

In our case of reankylosis previously treated by temporalis muscle flap, the causes of failure which may be, inadequate blood supply, muscle shrinkage, as full coverage of the temporalis muscle on the medial surface of the joint may not have been done. The operative notes and submandibular scarring were absent. This led us to think of other better autologous alternative as fascia lata that had more advantages.

Any surgical approach for TMJ may cause immediate and delayed complications like, vascular injury and hemorrhage, facial nerve paralysis or transient injury to nerve, infection, otologic complications due to injury to external acoustic canal, malocclusion, recurrence of ankylosis, trismus and pain in temporal region. However, the unwanted distressing complications are limited mouth opening and reankylosis.

In any case, joint architecture with disc and blood supply cannot be ideally created. Till date, no ideal interpositional graft is available because of problems encountered with the various available material, temporalis muscle with fascia showed some degree of degenerative changes, persistence of postoperative pain, atrophy or fibrosed muscle, fibrous adhesion, and temporalis fascia as interpositional graft lacks the bulk [10],[16].

Lateral thigh fascia lata has some advantages of its usage in surgery. It is strong, pliable, resistant to resorption and easily sutured to native tissues. It is easily harvested and no important nerves or vessels are encountered during surgical approach, the harvesting time ranging from 15 to 20 min.

Some of the complications are external scar on the lateral side of thigh, hematoma, dehiscence, nerve injury (distal branches of lateral cutaneous nerve) and muscle herniation [16]. For harvesting of lateral thigh fascia lata, a multidisciplinary approach involving the support of an orthopedic surgeon was opted. Interdisciplinary help make it safe, easy and without complication.

Follow-up for 3 years with no signs or symptoms of recurrence or decrease in mouth opening was observed. The average mouth opening till date is 40 mm.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors sincerely thank Dr Paul V Joseph (MDS FDSRC, Kochi, Kerala, India) Consultant Oral and Maxillofacial Surgeon for his valuable advice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gundlach KK. Ankylosis of the temporomandibular joint. J Craniomaxillofac Surg 2010; 38:122–130.  Back to cited text no. 1
    
2.
Sidebottom AJ, Salha R. Management of temporomandibular joint in rheumatoid disorders. Br J Oral Maxillofac Surg 2013; 51:191–198.  Back to cited text no. 2
    
3.
Chossegros C, Guyot L, Cheynet F, Blanc JL, Gola R, Bourezak Z, et al. Comparison of different materials for interpositional arthroplasty in the treatment of temporomandibular joint ankylosis surgery; long-term follow-up in 25 cases. Br J Oral Maxillofac Surg 1997; 35:157–160.  Back to cited text no. 3
    
4.
Narang R, Dixon RA Temporomandibular joint arthroplasty with fascia lata. Oral Surg Oral Med Oral Pathol 1975; 39:45–50.  Back to cited text no. 4
    
5.
Pogrel MA, Kaban LB. The role of the temporalis fascia and muscle flap in temporomandibular surgery. J Oral Maxillofac Surg 1990; 48:14–19.  Back to cited text no. 5
    
6.
Wagner JD, Mosby EL. Assessment of proplast-teflon disc replacement. J Oral Maxillofac Surg 1990; 48:1140–1144.  Back to cited text no. 6
    
7.
Paterson AW, Shepherd JP. Fascia lata interpositional arthroplasty in the treatment of temporomandibular joint ankylosis caused by psoriatic arthritis. Int J Oral Maxillofac Surg 1992; 2:137–139.  Back to cited text no. 7
    
8.
Shah D, Managutti A, Shah B, Urolagin S, Patel J. Interpositional arthroplasty with temporomyofascial flap to correct TMJ reankylosis in child: a case report. IJSS Case Reports Rev 2015; 1:35–40.  Back to cited text no. 8
    
9.
Matsuura H, Miyamoto H, Ogi N, Kurita K, Goss AN. The effect of gap arthroplasty on temporomandibular joint ankylosis: an experimental study. Int J Oral Maxillofac Surg 2001; 30:431–437.  Back to cited text no. 9
    
10.
Balaji SM. Modified temporalis anchorage in craniomandibular reankylosis. Int J Oral Maxillofac Surg 2003; 32:480–485.  Back to cited text no. 10
    
11.
Erdem E, Alkan A. The use of acrylic marbles for interposition arthroplasty in the treatment of temporomandibular joint ankylosis: follow up of 47 cases. Int J Oral Maxillofac Surg 2001; 30:32–36.  Back to cited text no. 11
    
12.
Kameros J, Himmelfarb R. Treatment of temporomandibular joint ankylosis with methyl methacrylate interpositional arthroplasty: report of four cases. J Oral Maxillofac Surg 1975; 33:282–287.  Back to cited text no. 12
    
13.
Macintosh RB. The use of autogenous tissues for temporomandibular joint reconstruction. J Oral Maxillofac Surg 2000; 58:63–69.  Back to cited text no. 13
    
14.
Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001; 30:189–193.  Back to cited text no. 14
    
15.
Kaban LB, Perrott HD, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990; 48:1145–1151.  Back to cited text no. 15
    
16.
Ramon MA, Maria GM. Lateral thigh fascia lata as interpositional graft for temporomandibular joint ankylosis. J Maxillofac Oral Surg 2012; 11:354–357.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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