Temporomandibular joint ankylosis involves fusion of the mandibular condyle to the base of the skull. It is a major clinical problem that affects many patients suffering from facial trauma, infection or systemic disease. The treatment of Temporomandibular joint ankylosis poses a significant challenge because of technical difficulties and a high incidence of recurrence. This report describe a rare case of a 16 year-man with complete inability to open his mouth, diagnosed with unilateral post septic left bony Temporomandibular joint ankylosis. The surgical approach consisted of gap arthroplasty followed by vigorous physiotherapy

Baruah, B

Ilapakurty, B

Kesari, SP

Sengupta, S

Cognitive Sciences ePrint Archive

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Case Report: 
A Rare Case of Post Septic Temporomandibular Joint Ankylosis 
Authors 
Binayak Baruah, Assistant Professor, 
Subhabrata Sengupta, Associate Professor, 
Bhargaw Ilapakurty, Post Graduate Trainee, 
Santosh Prasad Kesari, Post Graduate Trainee, 
Department of ENT, Sikkim Manipal Institute of Medical Sciences, Gangtok, India. 
Address for Correspondence 
Dr Binayak Baruah, 
Assistant Professor, Department of E.N.T. 
Sikkim Manipal Institute of Medical Sciences, 
5th mile, Tadong, 
Gangtok, Sikkim – 737 102, 
India.  
E-mail: binayak_binit@rediffmail.com 
Citation 
Baruah B, Sengupta S, Ilapakurty B, Kesari SP. A Rare Case of Post Septic Temporomandibular Joint Ankylosis.Online J Health 
Allied Scs. 2013;12(2):17 Available at URL: http://www.ojhas.org/issue46/2013-2-17.html 
Open Access Archives 
http://cogprints.org/view/subjects/OJHAS.html 
http://openmed.nic.in/view/subjects/ojhas.html 
Submitted: Mar 17, 2013; Accepted: Jun 15, 2013; Published: Aug 25, 2013 
Abstract: Temporomandibular joint ankylosis involves 
fusion of the mandibular condyle to the base of the skull. It is 
a major clinical problem that affects many patients suffering 
from facial trauma, infection or systemic disease. The 
treatment of Temporomandibular joint ankylosis poses a 
significant challenge because of technical difficulties and a 
high incidence of recurrence. This report describe a rare case 
of a 16 year-man with complete inability to open his mouth, 
diagnosed with unilateral post septic left bony 
Temporomandibular joint ankylosis. The surgical approach 
consisted of gap arthroplasty followed by vigorous 
physiotherapy.  
Key Words: Temporomandibular joint disorders; Ankylosis; 
Gap arthroplasty 
 
Introduction 
Temporomandibular joint (TMJ) ankylosis is a disorder that 
leads to a restriction of the mouth opening from partial reduc-
tion to complete immobility of the jaw. It is most commonly 
associated with trauma. Local or systemic infection or 
systemic disease, such as ankylosing spondylitis, rheumatoid 
arthritis, or psoriasis are a rarity.(1,2) 
TMJ ankylosis may be classified by a combination of 
location (intra- or extra-articular), type of tissue involved 
(bony, fibrous, or fibro-osseous) and extent of fusion 
(complete, incomplete).(3) Literature classifies ankylosis as 
true and false. Any condition that gives rise to osseous or 
fibrous adhesion between the surfaces of the temporo-
mandibular joint is a true ankylosis. False ankylosis results 
from pathologic conditions not directly related to the 
joint.(1,4) It may be caused by enlargement of the coronoid 
process, depressed fracture of the zygomatic arch, scarring 
from surgery, radiation,etc. 
The TMJ ankylosis is a extremely disabling affliction that 
causes problems in mastication, digestion, speech, 
appearance, and hygiene.(5) In growing patients, deformities 
of the mandible and maxilla may occur together with 
malocclusion.(6,7) There is no consensus in the existing 
literature of the best treatment for TMJ ankylosis. Several 
authors studied and developed different techniques, but 
recurrence still remains the major problem when treating 
TMJ ankylosis.(1,2,5,8) Inadequate exposure of the TMJ 
region often leads to insufficient removal of the ankylotic 
bone, thus leading to a recurrence of the problem. (3,7) 
The purpose of this paper is to highlight this rare case of post 
septic temporomandibular joint ankylosis. 
Case Report 
A 16 year old male presented to our department with chief 
complaint of inability to open his mouth since 6 years of age. 
He gave history of fever along with some swelling in his 
inguinal region when he was six years old. After about two 
weeks, he gradually found that he was unable to open his 
mouth fully. The disease progressed and within a year and 
half , his mouth opening was so restricted that he could 
barely open his mouth. On examination, we found severe 
trismus (grade 4). He also was having mandibular 
retrognathism.( Figure 1) His Ear and nose examination were 
normal. All his blood parameters were normal. His Chest x-
ray as well as X-ray of his cervical and/thoraco-lumbar spine 
were normal. CT scan and MRI mandible suggested left 
sided osseous fusion of the mandibular ramus with the 
fronto-temporal bone. The left TMJ, the condylar and 
coronoid processes are not seen separately. 
After complete evaluation, a surgical treatment with gap 
arthroplasty was planned under general anesthesia. Gap 
arthroplasty is a term used to describe the operation in which 
 
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Volume 12, Issue 2; Apr-Jun 2013 
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a section of bone is removed and no substance is interposed 
between the two cut bony surfaces The hair in the left 
temporal region was shaved .The TMJ approach consisted of 
a preauricular hockey stick shaped incision.(8) Dissection 
was carried out through the superficial temporal fascia, which 
was retracted anteriorly to protect the facial nerve, and the 
periosteum over the zygomatic arch was incised. 
After exposing the joint and identification of the site of the 
ankylosis, aggressive excision of the bony mass was done 
using drills and electric saw, creating a gap of at least 25 mm 
between the roof of the fossa and the mandible. After 
vigorous irrigation with saline, suction drains were placed 
after the resection to avoid edema and infection. The 
incisions were closed, and a pressure dressing was applied. 
The post-operative course was uneventful. A mouth opening 
of 12 mm was noted 2 days after surgery. Vigorous post-
operative physiotherapy was started to maintain the mobility 
of the joint. After 5 days with physiotherapy using wooden 
spatula, mouth opening was noted to be 25 mm.(Figure 2) 
The patient was instructed to continue with exercises for at 
least a period of 1 year. 
 
Figure 1: Pre operative mouth opening of the patient 
Discussion 
The causes and treatment of TMJ ankylosis have been well 
documented, with trauma and infection identified as the two 
leading causes. TMJ ankylosis can result in mandibular 
retrognathism with esthetic and functional deficits. 
Therefore, treatment should be initiated as soon as the 
condition is recognized, with the main objective of re-
establishing joint function along with harmonious jaw 
function. Infection of the TMJ most commonly occurs 
secondary to contiguous spread from otitis media or 
mastoiditis, but it may also result from hematogenous spread 
of infectious conditions such as tuberculosis, gonorrhea or 
scarlet fever. To prevent surgical recurrence in cases afflicted 
with ankylosis, radical removal of the bony or fibrous 
ankylotic segment is essential. (7,9) However the unfavorable 
anatomic configuration and the proximity of vital structures 
like the facial nerve make the surgical procedure particularly 
difficult.(8) 
 
Figure 2: Mouth opening on the 5th post operative day 
 
Figure 3: Post operative X Ray 
Roychoudhury et al. (5) recommended a gap of at least 15 
mm between the recountoured glenoid fossa and the 
mandible and subjected this gap to extensive active jaw 
opening exercises to prevent re-ankylosis when using gap 
arthroplasty. In our case the gap was in accordance with this 
recommendation. 
According to Kaban et al. (9) the advantages of gap 
arthroplasty are its simplicity and short operating time and 
the disadvantages include creation of a pseudoarticulation 
and a short ramus, failure to remove all the bony pathology, 
and increased risk of reankylosis. A careful surgical 
technique, and subsequent meticulous attention to long-term 
physiotherapy are both considered essential to achieve a 
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satisfactory result. (10) Many studies have shown that the 
choice of interposition material is important in preventing 
recurrence. (6) Interposition of autogenous or alloplastic 
material at the osteotomy site is a mechanism to prevent re-
currence; however, there are possible disadvantages, such as 
morbidity at the donor site and unpredictable resorption when 
autogenous material is used, and the risk of a foreign body 
reaction when alloplastic material is used. (10)  
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A Rare Case of Post Septic Temporomandibular Joint Ankylosis

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