|Year : 2012 | Volume
| Issue : 3 | Page : 156-160
A unique case of trauma from occlusion: TMJ fibrous ankylosis
Ashish Chaturvedi1, Monali Rawal2
1 Department of Prosthodontics, Crown and Bridge, JCD Dental College, Sirsa, Haryana, India
2 Department of Radiology, Dr. Lal Path Labs Indirapuram, Ghaziabad, India
|Date of Submission||20-Sep-2012|
|Date of Acceptance||23-Nov-2012|
|Date of Web Publication||29-Apr-2013|
Department of Prosthodontics, A-12 Ground floor, Aditya Corporate Hub, RDC Rajnagar, Ghaziabad - 201 002
Source of Support: None, Conflict of Interest: None
The temporomandibular joint is one of the most important yet most poorly understood joint of the human body. In a study, it was found that about 59% (56.6% males and 62.5% females) of subjects exhibit one or more signs of TMJ dysfunction. Although there are relatively few patients who develop such a degenerative change in TMJ that requires a surgical intervention; yet small adhesions, fibrous ankylosis, and other age changes like subluxation etc., are common findings. Conservative management protocol can provide favorable and long lasting solution.
Complete ankylosis is a very rare finding, so the decision to opt for conservative techniques or a more permanent surgical cure is highly controversial, since in most of the cases the problem is an incidental finding, therefore proper clinical diagnosis, accurate radiological assessment, judgment of the prognosis and winning the patient's confidence are all important components in the management of these cases.
Keywords: Ankylosis, degenerative, glenoid fossa, multidisciplinary, obliteration
|How to cite this article:|
Chaturvedi A, Rawal M. A unique case of trauma from occlusion: TMJ fibrous ankylosis. Indian J Oral Sci 2012;3:156-60
| Introduction|| |
Ankylosis of temporomandibular joint (TMJ) is defined as the union of condyle to articular surface of glenoid fossa. The union of condyle disc complex to temporoarticular surface subsequently restricts the mandibular movement. This condition could be a primary congenital defect or secondary to trauma, infections, post surgical union or systemic diseases (ankylosing spondilitis, rheumatoid arthritis etc.)
Depending upon the anatomic site of the ankylosis with respect to the joint itself, the TMJ ankylosis is of two types intra articular and extraarticular ankylosis.  Intraarticular ankylosis is one where the joint undergoes progressive destruction of the meniscus with degeneration of the glenoid fossa and condyles with resultant narrowing of the joint spaces. This type of ankylosis basically is of fibrous type. Ossification in the scar may however result in bony union in chronic cases. Extraarticular ankylosis is the splinting of the TMJ by fibrous or bony mass external to the joint proper, as in the case of infection of the surrounding bone or extensive tissue destruction.
Although TMJ ankylosis is a serious and disabling condition that causes difficulty in mastication, swallowing, speaking, esthetics, digestion, oral hygiene, facial asymmetry and rampant caries, yet it has been reported that about one third of these patients have never complained of any TMJ pain or dysfunction. These patients however complained of pain on palpation of muscles of mastication on random examination.  These signs could develop into a recognizable temporomandibular joint dysfunction at later period so an early recognition of these signs could prove highly beneficial.
Severity of the condition can be assessed by the degree of mouth opening, X-ray, CT scan and MRI scan. The treatment of TMJ ankylosis poses a significant challenge because of the technical difficulties and high incidence of recurrence. Management therefore rests on team approach involving surgeon, speech therapist, orthodontist, cosmetic dentist and sometimes psychiatrist. 
| Case Report|| |
A 53 year old lady complained of limited jaw opening with moderate to severe pain in the joint region, especially on right side. She had difficulty in mastication more so for large pieces of bolus which were nearly impossible to eat. She had also started developing difficulty in phonation of certain words due to which she was going through a high level of mental-psychological depression and had concern and apprehension about the prognosis.
Oral examination revealed a RCT treated right maxillary first premolar with ceramo-metal crown on the same tooth with similar crown on left maxillary first molar. There was continuous mild grade tenderness in right maxillary first premolar which the patient confirmed was present since many years. The occlusal anatomy of the crowns and opposing teeth was grossly disturbed with lots of lateral excursive interferences. Opening and closing jaw movements led to the shifting the midline towards the left side; however the jaw opening was almost 10-12 mm. at the level of central incisors.
The patient was sent for the radiographic evaluation. A CBCT study was conducted with CS 9300 scanner at voxel resolution (0.2 mm × 0.2 mm × 0.2 mm). 3D, cross-sectional and panoramic images were taken which revealed a suspicious old fracture of right TMJ condylar head in the medial third, with a detached condylar head fragment lodged in the antero-medial third of the joint space. There were secondary mild to moderate degenerative changes [Figure 1] with right TMJ condylar head noted as flattening of condylar head with slight irregularity and erosions along articular surface as well as increased thickness of roof of glenoid fossa [Figure 2] and [Figure 3] measuring about 2.6 mm as against the normal of 0.7-0.9 mm on left side (ref 0.5-1.5 mm). This was accompanied with generalized reduction of right TM joint space and near total obliteration of the anterior joint space in the medial third of the joint [Figure 4] and [Figure 5], without obvious evidence to suggest bony union between condylar head and temporal components [Figure 4] and [Figure 5]; implying secondary fibrous ankylosis. left TMJ appeared close to normal with concavo-convex shape, intercondylar axis of 160 (ref 135-160), normal glenoid fossa roof and certain obvious ageing changes suggesting mild left TMJ degenerative arthropathy [Figure 6],[Figure 7] and [Figure 8].
|Figure 1: Right TMJ 3D image showing bony degeneration of condyle as well as glenoid fossa in the medial joint space|
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|Figure 3: Right TMJ with thickening of the roof of the glenoid fossa, near obliteration of the joint space, the remaining space is relatively more radiodense when compared to the left side and bony fragment can be visualized in anterior part of the joint|
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|Figure 7: Left TMJ with near normal anatomy, uniform joint space and centrally positioned condyle|
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The CBCT findings suggest joint remodeling and secondary degenerative changes following old trauma. Trauma is among the common precursors to TM joint ankylosis A loose ossesous fragment causing obliteration of antero-medial joint space was also seen (this could represent a detached osseous fragment or discal calcification). Therefore, fibrous ankylosis was an implied diagnosis or an inference derived by corroboration of patient history, clinical data and imaging findings.
The moderate degenerative changes noted in this TM joint, presence of joint space calcification loose osseous speck suggest chronic secondary degenerative arthropathy. TMJ internal derangement is an expected finding in such cases, which does not significantly alter the disease prognosis or treatment plan. Hence, further work-up with TMJ-MRI was not considered, also from an economic perspective.
| Treatment Plan|| |
This patient was managed very patiently with the sound understanding of the fact that a multidisciplinary approach was the key for success.
Ceramo-metal crowns were removed; temporary crowns with only centric contacts were given. All lateral excursive interferences including cuspal slopes were reduced and disoccluded to prevent any trauma from horizontal mandibular movement. This comforted the strained joint from the inflammation caused by very long standing, continuous episodes of traumatic occlusion. As a result trauma from occlusion, fibrous TMJ ankylosis in this case, was gradually partially relieved.
Patient was advised a low grade NSAID with muscle relaxant to counter any development of muscle spasm that could have created a dilemma about the origin of pain locus. Serratiopeptidase was also advised to cover the risk of patient developing any exudates during rigorous controlled jaw movements.
Moist heat was advocated before starting the physiotherapeutic maneuver. This facilitated the relaxation of the tissues of the joint complex, thereby easing the comfortable opening of the mandible and eliminating the extreme risk of the condylar fracture.
A special custom made jig was used to assist controlled opening of mandible and simultaneously to assess the inter-arch distance at the level of incisors. This was recorded every time patient underwent for the session to track the patient's progress. Relative analysis and comparison of the sessions was done later.
Physiotherapy included diathermy, infrared and ultrasound treatment. Neuromuscular readjustment through a habit breaking appliance for bruxism was done along with orthodontic correction for certain habitual comfortable positions in occlusion that patient had developed to avoid the sore bite.
Positive patient counseling was done and once patient was successfully relieved of the pain, she could comfortably open the jaw well within the optimal limit for the regular day to day requirements of hygiene, mastication, swallowing etc., She was suggested maintenance protocol at home. Regular monthly appointments were planned to check progress and keep patient motivated.
Temporomandibular joint ankylosis is a challenging problem, surgical correction is technically difficult and incidence of recurrence after treatment is high.  Since in this case the patient is having a fibrous ankylotic tag in the antero-medial quadrant of the TMJ; the surgical approach was anatomically restricted. Besides; not many competent and confident hands are available in this sector those fit well within the economic range of the patient. 
| Discussion|| |
There are numerous causes of ankylosis which can be classified in many ways. In this patient two obvious factors resulting in the fibrous ankylosis were the defective crowns with occlusal interferences that led to the patient developing the habit of bruxism. This in turn caused excessive traumatic occlusion on chronic and continuous basis. This patient initially developed small adhesions in the antero-medial part of the joint. Degenerative changes were seen in that part of the meniscus. Some part of the adhesion got calcified and because of the excessive manipulative effort to open the jaw against resistance caused by this adhesion, a small piece of bone of condylar head got fragmented. This was visualized as a detached condylar head segment and slight articular surface irregularity or erosion in the adjoining medial third of condylar head. The osseous irregularity along with a low grade pain and restricted joint opening further led to chronic secondary mild to moderate degenerative change in the condylar head. Patient developed a comfortable position to masticate from left side ignoring the sequel of vicious cycle that was causing chronic progressive ankylosis of right TMJ.
This patient was then advised various steps of the cascade of management procedures.  As there was reduced joint space on the right side with almost obliteration in the antero-medial quadrant, surgical intervention with possibly gap arthroplasty was also suggested. The psychological mindset of the patient at that time and limited availability of the surgical resources coupled with the economic constrains led us to reach at a much feasible alternative conservative management,  procedure. With certain limitations and slight compromise with the complete cure, the procedure was highly accepted by our team and the patient.
Therefore, this zone of TMJ problem is still grey. Not many of our fellow colleagues are really practicing it. It is difficult to get expert hands in this area of practice to reach at a much conclusive results in most parts of our country. However, in contrast to this, conservative alternative of age old positioning appliance along with use of exercise combined with gentle manual therapy technique and moist heat provided sustained relief.
Patient was advised to limit the parafunctional activities such as nail biting, gum chewing, clenching and grinding teeth. Tongue positioning was suggested. At rest the tip of the tongue should be at the ridge of the roof of the mouth with the front one third of the tongue on the roof of the mouth when yawning. Patient was asked to avoid sleeping in the prone position. Patient was also told not rest the chin in hands. A soft diet devoid of hard crunchy foods was suggested along with smaller measures like dividing the bolus into small bites along with warm water rinses. The timely intervention of defective sore crowns with many interferences and high points could have avoided the occurrence of this problem.
| Conclusion|| |
Ankylosis of TMJ, whether bony or fibrous, complete or partial, is very incapacitating of the all diseases involving this structure. The patient may not be able to open his mouth to any appreciable extent.
In this case although the patient was having a localized fibrous intra-articular ankylosis secondary to a very low grade chronic persistent trauma, the patient was having a very high level of psychological dissatisfaction due to limitation of mandibular movements causing difficulty in mastication, swallowing and phonation.
Multiple patient counseling sessions, positive confidence building measures, continuous and rigorous physical manipulation keeping in mind the tenderness of the situation and regular motivation enforced and strengthened the treatment planned and thus provided a great deal of success in this case.
Therefore a multidisciplinary approach by team work for the treatment of TMJ ankylosis is best for the outcome of the desired results with the achievement of the normal form, function and stability.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]