CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART ONE

J Oral Maxillofac Surg

67:1966-1978, 2009

A Protocol for Management

of Temporomandibular Joint
Ankylosis in Children
Leonard B. Kaban, DMD, MD,*
Carl Bouchard, DMD, MSc, FRCD(C),† and
Maria J. Troulis, DDS, MSc‡

Temporomandibular joint (TMJ) ankylosis in children is a challenging problem. Surgical correction

is technically difficult and the incidence of recurrence after treatment is high. The purpose of the
present report is to describe the protocol currently used at the Massachusetts General Hospital for
the management of TMJ ankylosis in children. It has been our observation that the most common
cause of treatment failure is inadequate resection of the ankylotic mass and failure to achieve
adequate passive maximal opening in the operating room. The 7-step protocol consists of 1 )
aggressive excision of the fibrous and/or bony ankylotic mass, 2 ) coronoidectomy on the affected
side, 3 ) coronoidectomy on the contralateral side, if steps 1 and 2 do not result in a maximal incisal
opening greater than 35 mm or to the point of dislocation of the unaffected TMJ, 4 ) lining of the TMJ
with a temporalis myofascial flap or the native disc, if it can be salvaged, 5 ) reconstruction of the
ramus condyle unit with either distraction osteogenesis or costochondral graft and rigid fixation, and
6 ) early mobilization of the jaw. If distraction osteogenesis is used to reconstruct the ramus condyle
unit, mobilization begins the day of the operation. In patients who undergo costochondral graft
reconstruction, mobilization begins after 10 days of maxillomandibular fixation. Finally (step 7), all
patients receive aggressive physiotherapy. A case series of children with ankylosis treated using this
protocol is presented.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1966-1978, 2009

Temporomandibular joint (TMJ) ankylosis in chil-
dren is uncommon and is one of the most difficult
and complex problems managed by oral and max-
illofacial surgeons. Ankylosis is not only challeng-
ing to treat from a technical perspective, but, in
children, the surgeon must also consider the poten-
tial effects of time and growth (ie, the fourth di-
mension) on the outcome. The cognitive and emo-
tional development of the patient and the role of
the parents are other factors that can affect the
management and treatment results in children.
TMJ ankylosis in the pediatric patient often leads
to facial deformity, difficulty chewing and swallow-
ing, and poor oral hygiene. In some cases, particu-

Received from the Department of Oral and Maxillofacial Surgery,
Massachusetts General Hospital, Harvard School of Dental Medi-
cine, Boston, MA.
*WC Guralnick Professor and Chairman.
†AO/Synthes/MGH Fellow in Pediatric Oral and Maxillofacial
Surgery.
‡Associate Professor and Residency Program Director.
This work was supported in part by the AO/Synthes/MGH Fel-
lowship in Pediatric Oral and Maxillofacial Surgery; the Hanson
Foundation (Boston, MA), and the Massachusetts General Hospital
Department of Oral and Maxillofacial Surgery Education and Re-
search Fund.
Address correspondence and reprint requests to Dr Kaban: De-
partment of Oral and Maxillofacial Surgery, Massachusetts General
Hospital, Warren Building 1201, 55 Fruit Street, Boston, MA 02114;
e-mail: lkaban@partners.org
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6709-0026$36.00/0
doi:10.1016/j.joms.2009.03.071

1966
KABAN, BOUCHARD, AND TROULIS
larly if it is the first child, the parents might not
notice the functional deficit because of the child’s
ability to compensate and to maintain speech and
nutrition. When the pediatrician, dentist, friend, or
relative points out the jaw asymmetry or lack of
motion, it may come as a surprise to the family.
TMJ ankylosis is classified by location (intra-artic-
ular or extra-articular), type of tissue involved (eg,
bone, fibrous, or fibro-osseous), and extent of fu-
sion (complete or incomplete).1 Trauma, radiother-
apy, surgical excision of TMJ tumors, infection, and
systemic disease can all result in mandibular hypo-
mobility.2,3 In third world countries, infection re-
mains the most common cause of TMJ ankylosis in
FIGURE 1. Ten-year-old girl with left TMJ ankylosis secondary to
local infection (otitis media). A, Frontal photograph demonstrat-
ing maximal mouth opening of 0 mm. B, Three-dimensional
computed tomographic scan reconstruction demonstrating bony
ankylosis between condyle and cranial base and coronoid
hyperplasia.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ
Ankylosis. J Oral Maxillofac Surg 2009.
1967
children. Local odontogenic, ear, and skin infec-
tions or osteomyelitis and systemic spread of osteo-
myelitis from the long bones are the most common
etiologies (Fig 1).
In developed countries, intracapsular and subcon-
dylar fractures are the most frequent causes of anky-
losis in children (Fig 2).4 Prolonged immobilization is
often associated with ankylosis, but excessive miner-
alization and bone formation in the healing fracture
region can also occur in children who have not been
placed into maxillomandibular fixation. Patients in
the deciduous dentition, with intracapsular and/or
comminuted fractures, are at the greatest risk for
developing ankylosis.5
Radiotherapy produces fibrosis, scarring, and indu-
ration of the soft tissues surrounding the TMJs. This
can ultimately result in intra-articular fibrous anky-
losis, but extra-articular restriction is more common.
Resection of a tumor involving the TMJ (eg, giant cell
tumor, fibro-osseous lesion, Langerhans cell histiocy-
tosis) can result in fibrosis at the surgical site and
limitation of jaw motion. Finally, systemic autoim-
mune disorders, including ankylosing spondylitis, ju-
venile rheumatoid arthritis, and psoriasis can result in
TMJ ankylosis.6-9
Many surgical techniques have been described
for the treatment of TMJ ankylosis and no strategy
has been uniformly agreed upon, underscoring the
difficulty of the problem. In addition, confusion and
a lack of consistency exist in the published data
regarding the definition of the various treatment
techniques. Gap arthroplasty, interpositional ar-
throplasty, and osteotomy across and excision of
the ankylotic mass within the TMJ have all been
described. Reconstruction of the ramus/condyle
unit with autogenous bone, such as a costochondral
graft (CCG),2,10,11 fibula,12,13 clavicle,14 iliac
crest,15 metatarsal head,16,17 or alloplastic materi-
al,18 have all been reported. No single method has
produced uniformly successful results. Limited
range of motion and reankylosis are the most fre-
quently reported complications.19,20
Specifically with regard to children, surgeons not
familiar with pediatric patients have significant mis-
conceptions. The most common is that children
cannot or will not cooperate with physical therapy
and hence will always have a poor outcome after
ankylosis release. Our experience has been quite
the opposite. The most frequent source of failure in
children treated for TMJ ankylosis has not been a
lack of patient cooperation but, rather, inadequate
ankylosis release. This is most commonly caused by
a failure to adequately excise the ankylotic mass,
resulting in failure to achieve complete, passive
opening (without the need for excessive force) in
the operating room. If excessive force is necessary
1968 MANAGEMENT OF PEDIATRIC TMJ ANKYLOSIS

FIGURE 2. Thirteen-year-old girl with right TMJ ankylosis secondary to trauma. A, Frontal photograph illustrating deviation of chin point to
affected side. B, Maximal incisal opening (20 mm). C, Coronal and D, 3-dimensional computed tomographic scan demonstrating
fibro-osseous ankylosis and coronoid process elongation.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ Ankylosis. J Oral Maxillofac Surg 2009.

to open the jaw intraoperatively, even more force
will be required postoperatively. Under these cir-
cumstances, physical therapy will be very painful,
and the operation doomed to failure, regardless of
the level of patient cooperation.
Imaging with fine-cut 3-dimensional computed
tomography allows surgeons to specifically identify
the location, extent, and anatomic relations of the
area of ankylosis. This results in more accurate
treatment planning and improves the possibility of
obtaining a successful outcome. The use of surgical
navigation will enable surgeons to execute these
complex operations more precisely and safely in
the future.21,22
The purpose of the present report is to describe
the protocol for the treatment of pediatric TMJ
ankylosis first described by Kaban et al23 in 1990
and currently used at the Massachusetts General
Hospital. The critical guiding principle of this pro-
tocol is the requirement for 3-dimensional, aggres-
sive excision of the ankylotic mass to achieve free,
passive movement of the jaw intraoperatively (Ta-
ble 1).
Protocol
The 7-step protocol is as follows: 1 ) aggressive
excision of the fibrous and/or bony ankylotic mass;
2 ) coronoidectomy on the affected side; 3 ) coro-
noidectomy on the contralateral side, if steps 1 and
2 do not result in a maximal incisal opening greater
than 35 mm or to the point of dislocation of the
KABAN, BOUCHARD, AND TROULIS 1969

Table 1. PROTOCOL FOR MANAGEMENT OF TMJ

ANKYLOSIS IN CHILDREN
1. Aggressive excision of fibrous and/or bony mass
2. Coronoidectomy on affected side
3. Coronoidectomy on opposite side if steps 1 and 2 do
not result in MIO of ⬎35 mm or to point of dislocation
of opposite side
4. Lining of joint with temporalis fascia or the native disc,
if it can be salvaged
5. Reconstruction of RCU with either DO or CCG and
rigid fixation
6. Early mobilization of jaw; if DO used to reconstruct
RCU, mobilize day of surgery; if CCG used, early
mobilization with minimal intermaxillary fixation (not
⬎10 days)
7. Aggressive physiotherapy
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ
Ankylosis. J Oral Maxillofac Surg 2009.
unaffected temporomandibular joint; 4 ) lining of
the joint with a temporalis myofascial flap or the
native disc, if it can be salvaged; 5 ) reconstruction
of the ramus condyle unit (RCU) with either dis-
traction osteogenesis (DO) or a CCG and rigid fix-
ation; 6 ) early mobilization of the jaw; and 7 )
aggressive physiotherapy.
EXCISION OF ANKYLOTIC MASS
The first step of the protocol is excision of the anky-
lotic mass (Fig 3). The TMJ is approached through a
preauricular incision with a temporal extension (hemi-
coronal incision) to expose the temporalis fascia and
muscle, zygomatic arch, ankylotic mass, and sigmoid
notch (if it remains).24 The periosteum over the arch
is incised horizontally, and the incision is continued
inferiorly over the bony or fibro-osseous mass and
extended to the identifiable unaffected portion of the
ramus. The masseter muscle is dissected off the zygo-

FIGURE 3. Intraoperative photographs of patient shown in Figure 2. A, Proposed preauricular incision, with coronal extension shown (red).
(Reprinted with permission from Kaban LB: Acquired temporomandibular joint disorders, in, Kaban LB, Trouis MJ (eds): Pediatric Oral and
Maxillofacial Surgery. Philadelphia, PA, WB Saunders, 2004.) B, Condyle fused to glenoid fossa with fibro-osseous ankylosis. C, Ankylotic
mass and coronoid process excised. D, Surgical specimen. Ankylotic mass (right) and wire attached to coronoid process (left) to facilitate its
removal.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ Ankylosis. J Oral Maxillofac Surg 2009.
1970 MANAGEMENT OF PEDIATRIC TMJ ANKYLOSIS

FIGURE 4. A, Temporalis flap outlined (malachite green), B, dissected, and C, then elevated and rotated over the zygomatic arch. (Reprinted
with permission from Kaban LB: Acquired temporomandibular joint disorders, in, Kaban LB, Trouis MJ (eds): Pediatric Oral and Maxillofacial
Surgery. Philadelphia, PA, WB Saunders, 2004.) D, Flap lining glenoid fossa and sutured to medial soft tissue. TM, deep portion of temporal
muscle; TF, temporalis flap; GF, medial aspect of glenoid fossa.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ Ankylosis. J Oral Maxillofac Surg 2009.

matic arch, exposing the posterior and anterior bor-
ders of the ramus, sigmoid notch, and coronoid pro-
cess.24
After exposure and identification of the site of
the ankylotic mass, zygomatic arch, temporalis mus-
cle, and whatever TMJ architecture remains, aggres-
sive excision of the fibrous and/or bony mass is
performed. If any TMJ anatomy is identifiable, the
superior osteotomy is extended into the joint to
separate the ramus from the skull base. If not, a safe
osteotomy is created to separate the ankylotic mass
from the skull base. If a sigmoid notch is identifi-
able, the inferior osteotomy is created from the
notch, extending posteriorly at least 1.5 to 2 cm
KABAN, BOUCHARD, AND TROULIS
below the margin of the ankylotic mass. Next, a
plane is dissected or created with osteotomes to
complete the separation of the ankylotic mass and
the roof of the glenoid fossa (skull base). Special
attention is directed to the medial aspect of the
joint to ensure total resection.
The medial resection is critical, and this anatomy
must be delineated on the preoperative computed
tomographic scan to ensure adequate tissue exci-
sion. Failure will occur if the entire ankylotic mass
is not removed. If a continuous mass has obliterated
1971
FIGURE 5. A, Costochondral graft harvested with no more than
1 to 2 mm of cartilaginous cap (arrow). B, Intraoperative pho-
tograph showing temporalis flap lining glenoid fossa and cos-
tochondral graft secured in place (different patient). C, Diagram-
matic representation of CCG and temporalis flap in place.
(Reprinted with permission from Kaban LB: Acquired temporo-
mandibular joint disorders, in, Kaban LB, Trouis MJ (eds): Pedi-
atric Oral and Maxillofacial Surgery. Philadelphia, PA, WB
Saunders, 2004.)
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ
Ankylosis. J Oral Maxillofac Surg 2009.
the sigmoid notch, the osteotomy can be carried
horizontally across the ramus to the anterior bor-
der. In these cases, the excision will include the
coronoid process.
A bur is used to reshape the skull base into a
glenoid fossa. If the ankylosis is a complication of
previous trauma, the displaced condylar fragment will
be attached on the medial side of the ankylotic mass
and should be removed. When the excision is com-
pleted, the gap should be 1.5 to 2.5 cm. The maximal
opening should be at least 35 to 40 mm (depending
1972 MANAGEMENT OF PEDIATRIC TMJ ANKYLOSIS
KABAN, BOUCHARD, AND TROULIS 1973

on age and size of the child), and the opposite con-
dyle should dislocate after adequate excision of the
ankylotic mass.
IPSILATERAL CORONOIDECTOMY (CONTRALATERAL,
IF NECESSARY)
In children with longstanding ankylosis, the ipsi-
lateral, and sometimes the contralateral, coronoid
processes become hyperplastic, thereby creating
additional obstructions to jaw movement (Fig 2D).
Through the hemicoronal incision, the masseter
attachment should have been completely dissected
off the zygomatic arch and the anterior border of
the ramus and the coronoid process exposed. A
hole is made at the base of the coronoid process,
and a wire is placed for traction (Fig 3D). The
osteotomy extends from the depth of the sigmoid
notch to the junction of the horizontal and vertical
rami of the mandible. Once the osteotomy is com-
pleted, the coronoid is placed on traction with the
wire, the remaining temporalis muscle and tendon
attachments are cut, and the entire coronoid is
removed. Removing only the tip of the coronoid or
simply doing a coronoidotomy is inadequate, be-
cause the coronoid reforms and becomes attached
and limited by the temporalis tendon and scar. The
masseter, lateral and medial pterygoid and tempo-
ralis muscles should now have been stripped off the
ramus.
If the maximal incisal opening (MIO) remains less
than 35 mm and/or if the opposite TMJ does not
dislocate at maximal opening after this step, the
contralateral coronoid is also excised. The hemi-
coronal incision is usually extended into a full coro-
nal incision for the contralateral coronoidectomy.
Alternatively, the procedure can be accomplished
by way of an intraoral incision.
GLENOID FOSSA LINING
If an intact disc is identified during resection of
the ankylotic mass, it is dissected, mobilized, and
repositioned to line the roof of the new glenoid
fossa (Fig 4). In other cases, the TMJ is lined with
a previously described inferiorly based temporalis
muscle fascia flap rotated over the arch into the
joint.25,26 The temporalis flap is pedicled inferiorly on
the deep temporal artery. The thickness of the flap is
dictated by the joint space requirement. At a mini-
mum, the deep temporalis fascia and the superficial
muscle layer are transferred to construct a barrier, to
support the function of the reconstructed ramus/
condyle unit and to maintain flap vascularity. The flap
is sutured medially, anteriorly, and posteriorly to the
soft tissue with 4-0 monocryl suture (Ethicon, Somer-
ville, NJ).25,26
RECONSTRUCTION OF RAMUS/CONDYLE UNIT
Reconstruction of the ramus/condyle unit is shown
in Figures 5, 6.
Reconstruction With Costochondral Graft
After resection of the condyle, coronoidectomy,
and lining of the joint, the patient is placed into
occlusion with a prefabricated occlusal splint. The
jaws are immobilized with maxillomandibular wire
fixation (MMF). The splint creates an open bite on
the affected side to permit settling of the bone
graft. Reconstruction of the ramus condyle unit
(RCU) is achieved with a CCG obtained by an in-
framammary incision. The cartilage is contoured to
be no more than 1 to 2 mm thick and should be
rounded at the edges. The rib is trimmed and con-
toured to produce a good bony interface (Fig 5).
Additional exposure of the lateral ramus is achieved
by a submandibular incision if the hemicoronal
exposure is inadequate for placement of the graft.
The cartilaginous articulating surface of the graft is
then placed against the temporalis flap through the
submandibular incision and rigidly secured with a
2.0-mm titanium bone plate (which functions as a
washer to prevent fracture of the rib graft) and
three 2.0-mm titanium screws. The wounds are
closed in layers.
The MMF is maintained for no more than 10 days,
depending on the thickness and rigidity of the CCG.
After release of the MMF, the occlusal splint remains
in place for 3 months, without adjustment, to main-
tain the open bite. The occlusal splint is then gradu-
ally adjusted by grinding off the maxillary side to
allow eruption of the maxillary teeth and to close any
residual open bite.

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™
FIGURE 6. Reconstruction of ramus condyle unit of patient shown in Figure 2. A, Diagram representation of procedure. Resection gap
illustrated by shaded area, and ramus condyle unit reconstructed by DO with semiburied distractor (Synthes). (Reprinted with permission from
Kaban LB: Acquired temporomandibular joint disorders, in, Kaban LB, Trouis MJ (eds): Pediatric Oral and Maxillofacial Surgery. Philadel-
phia, PA, WB Saunders, 2004.) B, End-distraction frontal, C, MIO, and D, lateral photographs. Physiotherapy was started immediately
postoperatively. Panoramic radiographs at E, beginning and F, end of distraction.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ Ankylosis. J Oral Maxillofac Surg 2009.
1974 MANAGEMENT OF PEDIATRIC TMJ ANKYLOSIS

FIGURE 7. Patient shown in Figure 2 at end of treatment. A, Ramus was length-

ened and asymmetry improved. B, Frontal, C, lateral, and D, MIO photographs,
20 months postoperatively. Corresponding E, frontal and F, lateral 3-dimensional
reconstruction images and G, coronal view of ramus condyle unit at 20 months
postoperatively. Ramus lengthening illustrated by space between footplates of
distraction device. TMJ motion was maintained, and MIO was 49 mm. At last
follow-up, she was undergoing orthodontic treatment to correct her pre-existing
dental malocclusion.
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ Ankylosis. J Oral
Maxillofac Surg 2009.
KABAN, BOUCHARD, AND TROULIS
Reconstruction Using DO
More recently, we have been reconstructing the
RCU using transport DO instead of a CCG when
possible (Figs 6, 7).3,27-32 The protocol is the same as
described in the previous section, except for the
reconstruction phase. After jaw mobilization and lin-
ing of the fossa with the temporalis muscle fascia flap
or the native disc (steps 1 to 4), the mandibular stump
is reshaped to make it narrow and rounded at the top.
A corticotomy is created distally, leaving enough bone
to serve as a transport disc. The distraction device is
secured, the corticotomy completed, and mobility of
the segment tested by activating the semiburied uni-
directional distraction device (Synthes, Paoli, PA).
The wound is then closed in layers.
Active distraction starts 2 to 4 days after the oper-
ation at a rate of 1 mm/day with a rhythm of 2 or 4
activations daily. Once the transport disc has con-
tacted the skull base, the distraction is stopped so as
not to create pressure on the flap or disc lining the
joint. The advantages of reconstruction using trans-
port DO are the lack of donor site morbidity and the
ability to start physical therapy the day of the opera-
tion.
Early Mobilization and
Aggressive Physiotherapy
After release of the MMF (for patients recon-
structed with the CCG) and immediately postoper-
atively for patients reconstructed with DO, the
physical therapy program is begun. It consists of
active hinge opening and lateral excursions com-
bined with manual finger stretching in front of a
mirror. The exercises are done 4 times daily for 3 to
5 minutes by the clock. At 6 weeks postoperatively,
the diet is advanced to solid foods, and the “Thera-
Bite Jaw Rehabilitation System” (CranioMandibular
Rehab, Denver, CO) is used 4 to 5 times daily for 3
to 5 minutes in both groups. The physical therapy
program also includes heat, massage, and gum
chewing.
If the patient is not able to achieve the documented
intraoperative MIO, or if the MIO shows no sign of
improvement at 6 to 8 weeks, the jaw should be
stretched with the patient under general anesthesia.
The use of the TheraBite 3 to 4 times daily, gum
chewing, and finger stretching exercises should be
continued for 1 year, and patients should be followed
closely for at least 1 year.
Results
Excellent results have been previously reported
with this protocol, with a mean MIO of 37.5 ⫾ 3.90
mm at 1 year in 14 patients with 18 affected joints.
The mean preoperative MIO was 16.5 ⫾ 9.06 mm.23
1975
In a more recent retrospective analysis of 11 chil-
dren younger than 16 years of age treated by this
protocol, 8 patients had ankylosis secondary to
trauma, 1 had hemifacial microsomia, 1 an infection,
and 1 congenital ankylosis. In 2 patients, both joints
were affected. The ramus condyle unit was recon-
structed with either a CCG (n ⫽ 6) or DO (n ⫽ 5). The
patients were followed for a period of 4 to 74 months
(mean 24.8). The mean preoperative MIO was 11.5
mm (range 1 to 23). Postoperatively, the mean MIO
was 38.2 mm (range 15 to 49). Ten of 11 patients had
an MIO greater than 30 mm after the operation and 1
had to have fibrous ankylosis release 6 years after the
first operation.
Discussion
Untreated TMJ ankylosis in children results in sig-
nificant adverse consequences. Facial asymmetry pro-
gressively worsens because of the hypomobility and
abnormal muscle function. The short ramus condyle
unit restricts mid-face growth. The longer the dura-
tion of hypomobility, the more severe will be the
muscle atrophy and facial asymmetry. In addition,
secondary elongation and hypertrophy of the coro-
noid process occurs, further restricting jaw motion.
The prognosis for a favorable outcome with treatment
is inversely related to the number of years of anky-
losis.
Therefore, treatment of ankylosis should be done as
soon as it is feasible to expect patient cooperation
after the operation. The surgeon and the surgical team
must take the time to explain to the child, in an
age-appropriate way, the operation and postoperative
physical therapy program. The parents’ help must be
enlisted, and they must be active participants in the
overall management. It is helpful to have a pediatric
nurse work closely with the family, and psychological
counseling for the patient and parents might be im-
portant in some cases. After thorough evaluation, the
operation might have to be delayed if it appears
unlikely that the patient and family can manage
with the procedure. These issues can be resolved in
most patients, and children 3 years of age or older
are considered candidates for ankylosis release. It is
not necessary and actually contraindicated to wait
for the completion of growth because the asymme-
try will progress with time if the ankylosis is left
untreated.33-36
Children 3 years of age and older can cooperate
with physical therapy, provided the ankylosis re-
lease is successful and excessive force to mobilize
the jaw is not necessary during the postoperative
period. Failure under these circumstances is a fail-
ure of the operation and not a failure of patient
1976 MANAGEMENT OF PEDIATRIC TMJ ANKYLOSIS

cooperation. Other benefits from early operation

include improved psychosocial development be-
cause of a more normal appearance, improved nu-
trition, improved oral hygiene and ability to obtain
dental treatment.
The variety of techniques described in the pub-
lished data for the treatment of TMJ ankylosis reflects
the complexity of the problem. Variable results have
been reported with gap arthroplasty, interpositional
arthroplasty and excision and joint reconstruction
with alloplastic or autogenous materials. Regardless of
the technique, a postoperative MIO greater than 35
mm is rarely achieved. In our experience, reankylosis
is most commonly caused by incomplete excision of
the bony and/or fibrous mass, specifically on the me-
dial aspect of the joint. In addition, many surgeons fail
to appreciate the role of the ipsilateral and contralateral
coronoid processes, along with the attached contracted
temporalis muscles, in the limitation of motion in chil-
dren with ankylosis. The protocol described in the
present report was developed to specifically address
these issues.
It is critical to have adequate surgical access to
expose and fully resect the ankylotic mass and to
perform the ipsilateral coronectomy. Therefore, we
use a hemicoronal incision. Once the ankylotic mass
has been removed, the joint must be lined with vas-
cularized tissue. This acts as a barrier to excessive FIGURE 8. A, Postoperative computed tomography scan at 5
bone formation, fusing the RCU to the skull base. A years and B, intraoperative photograph of patient who had had
right ramus condyle unit reconstructed with CCG and temporalis
vascularized temporalis myofascial flap is desirable for flap for degenerative joint disease. Photograph demonstrates
lining the joint because the donor site is in the surgi- viability and thickness of temporalis flap even after 5 years.
cal field, the muscle and fascia are of adequate thick- CCG remodeled and is anatomically similar to a normal
condyle.
ness, and its long-term viability has been demon-
Kaban, Bouchard, and Troulis. Management of Pediatric TMJ
strated (Fig 8).25,26 Ankylosis. J Oral Maxillofac Surg 2009.
Traditionally, the RCU was reconstructed using a
CCG. More recently, we have been lengthening the
residual ramus using transport DO. The benefits of micromotion occurs at the junction of the cartilage
a CCG include its growth potential,37-42 its biologic and bone during normal mandibular function. This
compatibility, and its capacity to remodel into a results in tumor-like overgrowth. Since we began to
neocondyle with time. Its major drawbacks are do- fashion the CCG to only include 1 to 2 mm of carti-
nor site morbidity and reported unpredictable lage, we have not experienced problems with over-
growth.10,43-45 growth.
Perrott and Kaban1 and Peltomaki et al46 hypothe- DO has the advantage of eliminating donor site
sized that the cause of overgrowth of CCGs is the use morbidity and allowing immediate mobilization of
of an excessively large cartilaginous cap. Peltomaki the jaw.3 Because no donor site operation is neces-
et al46 demonstrated this phenomenon in a rat model. sary, the child has considerably less discomfort
Perrott et al39 and Perrott and Kaban47 described 2 postoperatively and hence requires less pain medi-
types of overgrowth: 1) linear overgrowth resulting cation. This allows the patient to begin mobilizing
in asymmetric or bilateral prognathism; and 2) tumor- the jaw on the night of the operation. A major
like overgrowth and reankylosis. Both types of over- disadvantage is that a growth center is not trans-
growth are caused by an excessive cartilaginous cap planted. However, it is at least theoretically possi-
on the graft. The rib growth center is the costochon- ble that restoring normal motion and a symmetric
dral junction. A cartilaginous cap greater than 1 to 2 RCU length will allow future soft and hard tissue
mm transfers an excessive portion of the growth development.28 Long-term outcome studies of this
center, resulting in linear overgrowth. In some cases, method are required to document the actual post-
when a large cartilaginous cap has been transferred, operative growth pattern. Additional operations
KABAN, BOUCHARD, AND TROULIS
might be necessary to correct any residual asymme-
try after the end of growth.48
Physical therapy also plays an important role in
the treatment of pediatric patients with TMJ anky-
losis. A satisfactory surgical release and reconstruc-
tion can be negated by an inadequate postoperative
physiotherapy program or poor patient compli-
ance. It is preferable to delay an operation rather
than dealing with these issues after the surgical
intervention.
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