J Oral Maxillofac Surg

69:e565-e572, 2011

Two-Stage Treatment Protocol for

Management of Temporomandibular
Joint Ankylosis With Secondary
Deformities in Adults: Our
Institution’s Experience
Songsong Zhu, DDS,* Jihua Li, DDS,† En Luo, DDS,‡
Ge Feng, DDS,§ Yongqing Ma, DDS,储 and Jing Hu, DDS, PhD¶

Purpose: Treatment of adult patients with temporomandibular joint (TMJ) ankylosis and secondary
deformities is a challenging problem. Although various techniques, including arthroplasties, orthognathic
surgery, autogenous bone graft, and distraction osteogenesis, have been described for the management
of patients with this condition, an appropriate treatment protocol has not been established. The purpose
of this report is to describe a 2-stage treatment protocol, comprising TMJ reconstruction as the initial
surgery, followed by orthodontic treatment, and correction of secondary deformities as the second
surgery, for the management of TMJ ankylosis with secondary deformities in adults.
Patients and Methods: From January 2003 to December 2009, 24 adult patients (30 joints) with TMJ
ankylosis and secondary deformities underwent TMJ reconstruction as the initial surgery, followed by
orthodontic treatment and correction of secondary deformities as the second surgery. Clinical outcome
was assessed based on oral function, radiography, and medical photography.
Results: Patients were followed up for a minimum of 12 months to a maximum of 32 months (mean,
18.6 months). No relapse of TMJ ankylosis occurred in any patient during the follow-up period. Oral
function and skeletal deformities were significantly improved in all patients. Satisfactory occlusion was
achieved with the help of orthodontic treatment. Most of the patients were satisfied with the final
outcome.
Conclusions: The 2-stage treatment protocol described not only restores oral function but also im-
proves the patient’s esthetic appearance. We believe that it is a good approach for management of TMJ
ankylosis with secondary deformities in adult patients.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:e565-e572, 2011

Temporomandibular joint (TMJ) ankylosis is a serious
and disabling condition that may cause problems in
mastication, digestion, speech, appearance, and hy-
giene.1-3 When it occurs in children, it can cause
secondary dentofacial deformities, invariably resulting
in physical and psychological disability.4,5 The inci-
dence of TMJ ankylosis in developing countries is
high; an average of 40 patients with TMJ ankylosis are
referred to our department annually, and one-fourth
of them are adult patients with secondary deformities.
Treatment of adult patients with TMJ ankylosis and
secondary deformities remains a great challenge for
surgeons. Up to now, various techniques, including
arthroplasties, orthognathic surgery, autogenous

Received from the State Key Laboratory of Oral Diseases and De- Supported by a grant from the Ministry of Health of China.
partment of Oral and Maxillofacial Surgery, Sichuan University, Address correspondence and reprint requests to Dr Hu: Depart-
Chengdu, China. ment of Oral and Maxillofacial Surgery, West China College of
*Associate Professor. Stomatology, Sichuan University, Chengdu 610041, China; e-mail:
†Associate Professor. drhu@vip.sohu.com
‡Associate Professor. © 2011 American Association of Oral and Maxillofacial Surgeons
§Assistant Professor. 0278-2391/11/6912-0033$36.00/0
储Resident. doi:10.1016/j.joms.2011.07.025
¶Professor.

e565
e566 TMJ ANKYLOSIS WITH SECONDARY DEFORMITIES

bone graft, and distraction osteogenesis (DO), have

been described in the literature. However, no single
method has produced uniformly successful results. In
most cases these techniques should be used in com-
bination to achieve satisfactory outcomes. However,
the difficulty for many clinicians may lie in identifying
the proper sequencing of these procedures because
of the longstanding controversy associated with it.
Some surgeons recommend a staged approach for the
treatment of the patient with concomitant TMJ anky-
losis and secondary deformities,6-8 whereas others
prefer to release the ankylosis and perform correction
of secondary deformities simultaneously.9-11 We have
applied a 2-stage treatment protocol, composed of
TMJ reconstruction as the initial surgery, followed by
orthodontic treatment, and correction of secondary
deformities as the second surgery, for the treatment
of the patient with this condition since 2003. Our
experience with this approach is reported in this
prospective study.

Patients and Methods

PATIENTS
Between January 2003 and December 2009, 30
joints in 24 adult patients (aged ⬎18 years) with TMJ
ankylosis and secondary deformities underwent TMJ
reconstruction as the initial surgery. The surgery was
followed by orthodontic treatment and then correc-
tion of secondary deformities at the Orthognathic
and TMJ Centre at the West China Hospital of Sto-
matology, Sichuan University, Chengdu, China.
This study was approved by the local institutional
review board, and high standards of scientific re-
search ethics were applied in carrying out all as-
pects of this study.

TREATMENT

Surgery for TMJ Reconstruction

All patients underwent TMJ surgery through a stan-
dard preauricular incision with temporal extension.
Most patients underwent resection of ankylotic bony
mass, condylar reconstruction by autogenous coro-
noid process (costochondral graft was used if the
coronoid process was involved by ankylotic bone),
and interposition of temporalis fascia flap (articular
disc was used if available) (Fig 1A). In some patients
whose ankylotic mass was relatively small, it was
justifiable to resect the ankylosing mass and inter-
pose temporalis fascia flap in the resulting gap with
no reconstruction of the condyle. A contralateral
coronoidectomy was performed through an in-
traoral approach if the passive maximal opening
was less than 3 cm. Active physical exercises
should be started on the seventh day postopera-
FIGURE 1. A, Condylar reconstruction by autogenous coronoid
process graft and interposition of temporalis fascia flap (arrows). B,
Reversed L-shaped osteotomy and iliac bone graft (arrows).
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral
Maxillofac Surg 2011.
tively and continued for at least 6 months to reduce
the risk of relapse.
Surgery for Correction of Secondary Deformities
Le Fort I osteotomy was mainly performed to bring
the shortened hemimaxilla down and level the occlu-
sal canting in unilateral cases and to bring the poste-
rior maxilla down and for filling of the resulting gap
by bone graft in bilateral cases.
ZHU ET AL e567

Inverted or reversed L-shaped osteotomy of ramus
and iliac bone graft through a standard submandibular
incision (Fig 1B) or internal mandibular DO was ap-
plied to correct the mandibular deformity. Distraction
was started on the seventh postoperative day at a rate
of 0.5 mm twice daily, and the distractor was re-
moved after a 12-week consolidation period. No mat-
ter which technique was used, a 2- to 3-mm overcor-
rection was needed. In addition, an advancement
genioplasty was performed in all cases, and in unilat-
eral cases, sagittal split ramus osteotomy or intraoral
vertical ramus osteotomy was performed on the non-
affected side to set back the mandible.
Esthetic surgery was performed if needed, such as
reduction malarplasty. Clinical outcome was assessed
based on oral function, radiography, and medical pho-
tography. Relapse of ankylosis was confirmed if max-
imal incisal opening (MIO) was less than 20 mm.
STATISTICAL ANALYSIS
The preoperative MIO and postoperative MIO were
calculated and reported as mean values. Wilcoxon
matched-pair signed rank tests were performed to
compare the differences, and a value of P ⬍ .05 was
considered statistically significant. SPSS software (ver-
sion 11.5; SPSS, Chicago, IL) was used for statistical
analysis.
Results
The basic information and clinical details of the
patients are summarized in Table 1. There were 9
male and 15 female patients with a mean age of 26.1
years (range, 19-34 years). Patients were followed up
for a minimum of 12 months to a maximum of 32
months (mean, 18.6 months). No patients had any
infections during or after hospitalization, although
hematomas were observed in 2 patients. There were
no signs of reankylosis during the follow-up period.
All of the patients achieved satisfactory outcomes
with significant improvements in mouth opening (3.4
mm preoperatively to 32.5 mm postoperatively, P ⬍
.05) and esthetic appearance. Most of the patients
have maintained stable improvement in oral function
including pronunciation, chewing, swallowing, and
respiration with long-standing follow-up.
REPRESENTATIVE CASES
A 21-year-old female patient presented with a
right-sided TMJ ankylosis and severe facial asymme-

Table 1. PATIENT DATA

Patient Age (yr)/ Affected Surgical Procedures Mouth Opening (mm) Follow-Up
No. Gender Side TMJ Secondary Deformity Preoperative Postoperative (mo)

1 21/F R CPG ⫹ TFF LFO ⫹ RM ⫹ ILO ⫹ SSRO ⫹ GP 3 34 13

2 26/F L CPG ⫹ TFF LFO ⫹ ILO ⫹ IVRO ⫹ GP 0 35 21
3 28/M L CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 5 36 26
4 19/F B GA ⫹ TFF DO ⫹ GP 6 31 14
5 32/F R CPG ⫹ TFF LFO ⫹ ILO ⫹ IVRO ⫹ GP 0 31 32
6 34/M R CPG ⫹ TFF LFO ⫹ ILO ⫹ GP 6 27 15
7 29/F B CPG ⫹ TFF ILO ⫹ GP 0 36 22
8 32/M L CPG ⫹ TFF RM ⫹ ILO ⫹ IVRO ⫹ GP 7 33 16
9 24/M R CCG ⫹ TFF LFO ⫹ ILO ⫹ IVRO ⫹ GP 0 26 26
10 26/F R CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 0 31 23
11 18/F L CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 5 33 21
12 34/F B CPG ⫹ TFF LFO ⫹ DO ⫹ GP 4 29 17
13 25/M R GA ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 7 41 13
14 26/F L CPG ⫹ TFF LFO ⫹ DO ⫹ GP 3 33 14
15 23/F B CPG ⫹ TFF LFO ⫹ ILO ⫹ GP 0 28 17
16 22/F R CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 7 34 12
17 25/M B CPG ⫹ TFF DO ⫹ GP 3 32 14
18 21/M L CCG ⫹ TFF ILO ⫹ GP 2 27 15
19 24/F R CPG ⫹ TFF ILO ⫹ IVRO ⫹ GP 11 35 17
20 23/M R CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 7 32 22
21 27/M B CPG ⫹ TFF LFO ⫹ DO ⫹ GP 3 42 25
22 31/F L CPG ⫹ TFF LFO ⫹ ILO ⫹ IVRO ⫹ GP 0 32 14
23 28/F L GA ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 2 29 25
24 27/F R CPG ⫹ TFF LFO ⫹ ILO ⫹ SSRO ⫹ GP 0 32 12
Abbreviations: CCG, costochondral graft; CPG, coronoid process graft; F, female; GA, gap arthroplasty; GP, genioplasty; ILO,
inverted/reversed L-shaped osteotomy and iliac bone graft; IVRO, intraoral vertical ramus osteotomy; L, left; LFO, Le Fort I
osteotomy; M, male; R, right; RM, reduction malarplasty; SSRO, sagittal split ramus osteotomy; TFF, temporalis fascia flap.
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral Maxillofac Surg 2011.
e568 TMJ ANKYLOSIS WITH SECONDARY DEFORMITIES

try. She underwent right condylar reconstruction
by autogenous coronoid process and interposition
of temporalis fascia flap as the initial surgery. After
1 year of orthodontic treatment, she underwent
second surgeries including Le Fort I osteotomy to
bring the shortened hemimaxilla down and level
the occlusal canting, right inverted L-shaped osteot-
omy of ramus and iliac bone graft to move the
affected mandible anteriorly and inferiorly, sagittal
split ramus osteotomy on the left side to set back
the mandible, genioplasty to advance and bring the
chin to the midline, and lastly, reduction malar-
plasty on the left side. Significant improvements in
facial symmetry and occlusion were achieved, as
shown in Figure 2. Considerable increases in the
length, height, and width of her affected mandible

FIGURE 2. Photographs of a 21-year-old woman with right-sided TMJ ankylosis treated with right condylar reconstruction by autogenous
coronoid process and interposition of temporalis fascia flap. After 1 year of orthodontic treatment, she underwent second surgeries including
Le Fort I osteotomy, right inverted L-shaped osteotomy of ramus and iliac bone graft, sagittal split ramus osteotomy on the left side, genioplasty,
and reduction malarplasty on the left side. A, Frontal view before treatment; B, frontal view after treatment; C, lateral view before treatment;
D, lateral view after treatment; E, occlusion before treatment; F, occlusion after completion of treatment.
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral Maxillofac Surg 2011.
ZHU ET AL e569

FIGURE 3. Cephalograms of patient in Figure 2. A, Posteroanterior cephalogram before treatment; B, posteroanterior cephalogram after
treatment; C, lateral cephalogram before treatment; D, lateral cephalogram after treatment.
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral Maxillofac Surg 2011.

were shown on the posteroanterior and lateral
cephalograms (Fig 3).
A 29-year-old female patient presented with bilat-
eral TMJ ankylosis and severe bird-face deformity. She
underwent bilateral condylar reconstruction by autog-
enous coronoid process and interposition of tempo-
ralis fascia flap as the initial surgery (Fig 4), and
bilateral reversed L-shaped osteotomy of ramus and
iliac bone graft as well as genioplasty as the second
surgery. Significant improvements in facial deformity
(Fig 5) and upper airway were achieved, as shown in
Figure 6.
Discussion
Treatment for the adult patient with TMJ ankylosis
and secondary deformities aims at not only restoring
oral function but also improving the patient’s esthetic
appearance and quality of life. Our experience sug-
e570 TMJ ANKYLOSIS WITH SECONDARY DEFORMITIES

FIGURE 4. Photographs of a 29-year-old female patient who presented with bilateral TMJ ankylosis and severe bird-face deformity. She
underwent bilateral condylar reconstruction by autogenous coronoid process and interposition of temporalis fascia flap as the initial surgery.
A, Mouth opening before treatment; B, mouth opening after treatment; C, panoramic radiograph before TMJ surgery; D, panoramic
radiograph after TMJ surgery (arrows show the grafted coronoid process).
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral Maxillofac Surg 2011.

gests that a 2-stage treatment protocol can be a good
and effective approach for the treatment of adult
patients with TMJ ankylosis and secondary deformi-
ties and offers several advantages over a 1-stage pro-
tocol. First, orthodontic treatment in the adult patient
is made difficult by extensive dental compensations.7
Clearly, 1-stage surgery produces more significant
malocclusion and makes the orthodontic treatment
more difficult. In addition, unlike the case in young
children, it is difficult to use maxillary and mandibular
growth potential to adjust the occlusion in adults.
Therefore it is not clear whether the malocclusion
can be successfully managed after the 1-stage surgery
by orthodontic treatment. However, this problem
does not exist in a patient treated with a 2-stage
protocol, because orthodontic treatment can begin
after the release of TMJ ankylosis, which helps us to
correct skeletal deformities more precisely and obtain
a more stabilized outcome with a good occlusion.
Second, a stabilized TMJ is the foundation and sup-
port for jaw position, function, occlusion, and facial
balance. Clearly, arthroplasty can significantly alter
the position of the mandible and the occlusion.
Although condylar reconstruction by bone grafting
can reduce these changes, it is not stable or wors-
ens with time if graft resorption, a common com-
plication in adult patients, occurs. If surgeries for
skeletal deformities are performed before the TMJ
becomes stable, treatment outcomes may be un-
satisfactory relative to function, esthetics, and
stability. Third, early and active postoperative
mouth-opening exercises are mandatory for the
prevention of relapse.12-14 In our experience active
mouth-opening exercises are started immediately
after postoperative pain subsides and continue for
at least 6 months. In the 1-stage approach, active
ZHU ET AL e571

FIGURE 5. The patient in Figure 4 underwent bilateral reversed L-shaped osteotomy of ramus and iliac bone graft as well as genioplasty as
the second surgery. A, Frontal view before treatment; B, frontal view after treatment; C, lateral view before treatment; D, lateral view after
treatment.
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral Maxillofac Surg 2011.

mouth-opening exercises may cause movement of
the bony segment created during the surgery for
correction of skeletal deformities, thus increasing
the possibility of delayed bone healing, graft resorp-
tion, and pseudo-TMJ at the distraction site and
ultimately compromising the surgical outcomes. Fi-
nally, adult patients with TMJ ankylosis and second-
ary deformities usually are in a poor condition of
health. When considering the combined surgical
approach, operating room time and general anes-
thesia time increase with an attendant increase in
associated morbidity, and these ultimately increase
the potential risk of surgery.
In teenagers and young children, however, the
1-stage approach is our preferred protocol because
the degree of secondary dentofacial deformities is
usually less severe in young patients than in adult
patients. Thus the resultant malocclusion or occlusal
instability after the 1-stage surgery could be compen-
sated for by maxillomandibular growth. Furthermore,
simultaneous release of TMJ ankylosis and correction
of the facial deformity are also vital to a young pa-
tient’s psychosocial well-being.
In this study 2 surgical techniques—inverted/re-
versed L-shaped osteotomy and iliac bone graft and
DO—were used for correction of mandibular defor-
mity. Although both techniques were shown to be
effective, they have their own advantages and dis-
advantages. Inverted/reversed L-shaped osteotomy
leaves facial scar and requires exploration of a second
surgical site to harvest iliac bone graft, whereas DO
requires a long-term treatment period and requires
another surgery to remove the distractor.9-11,15 There-
fore selection of these surgical procedures for a par-
ticular case mainly depended on the patient’s prefer-
ence and compliance.
e572
FIGURE 6. Lateral cephalograms of patient in Figures 4 and 5
before (A) and after (B) treatment. Significant improvements in the
upper airway were achieved after surgery (arrows).
Zhu et al. TMJ Ankylosis with Secondary Deformities. J Oral
Maxillofac Surg 2011.
Different autogenous and alloplastic grafts have
been described for the reconstruction of mandibular
condyle. Our previous experimental and clinical stud-
ies have showed that autogenous coronoid process
could be considered a good donor source for recon-
struction of the mandibular condyle.16,17 Therefore
autogenous coronoid process is our preferred mate-
rial, instead of costochondral bone, for condylar re-
construction if ankylotic bone is not involved. This
technique has the advantages of eliminating donor-
site morbidity and minimizing the operation time.
Previous studies reported restoration of the posterior
TMJ ANKYLOSIS WITH SECONDARY DEFORMITIES
ramus height by grafting a longer coronoid process or
costochondral bone,18,19 which is not recommended
by the authors because it produced more stress load-
ing on the graft and aggravated possible bone resorp-
tion.
In conclusion, the 2-stage treatment protocol de-
scribed in this study not only restores oral function
but also improves the patient’s esthetic appearance.
Therefore we believe that it is a good approach for
management of TMJ ankylosis with secondary defor-
mities in adult patients.
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