J. Maxillofac. Oral Surg.

(Oct–Dec 2021) 20(4):702–705

https://doi.org/10.1007/s12663-021-01562-9

TECHNICAL NOTE

Treatment of the Temporomandibular Joint Ankylosis

with a Customized Prosthesis in a Single Stage: The Use of 3D
Cutting Guides and Virtual Surgical Planning
Jéferson Martins Pereira Lucena Franco1,2,3 • Tácio Pinheiro Bezerra2 •
Ivo Cavalcante Pita Pita-Neto3 • Daniel Facó da Silveira Santos1 • Roberto Dias Rêgo1

Received: 12 November 2020 / Accepted: 3 April 2021 / Published online: 25 April 2021
Ó The Association of Oral and Maxillofacial Surgeons of India 2021

Abstract less morbidity, in addition to being relatively simple and

Background Ankylosis of the temporomandibular joint can be easily picked up by young surgeons.
(TMJ) is a debilitating condition and disabling as a result of
craniomandibular fusion, which can result in trismus, pain Keyword Ankylosis; temporomandibular ankylosis;
and a poor quality of life. Current management includes temporomandibular joint; total joint prosthesis; virtual
interposition arthroplasty, gap arthroplasty, and recon- surgical planning
struction. Traditionally, the joints are reconstructed with
pre-made prostheses (in stock), or the procedure is per- Ankylosis of the temporomandibular joint (TMJ) is a
formed in two steps; with a computerized tomography condition in which the joint surfaces are fused either by
scan, its design is observed between the respective and bone or fibrous tissue, causing a debilitating condition that
reconstructive procedures. can interfere with speech, chewing, appearance, hygiene,
Study Design A technical note about the customization and normal life activities, in addition, it may cause
management of ankylosis of the temporomandibular joint. dentofacial deformity and asymmetry [1–4]. The present
Objective and Methods Describe a modification of tech- work aims to present a technical note on how to use a
nique using 3D surgical cutting and positioning guides prototyped 3D guide for the treatment of temporo-
digitally created to help determine the position and mandibular ankylosis.
dimensions of the osteotomies as an auxiliary tool in the
management of TMJ ankylosis, enabling the installation of
personalized prostheses in a single stage. Computer-Aided Planning
Conclusion This technique has the advantage of allowing
the installation of customized TMJ prostheses in a single The DICON files from the face computed tomography (CT)
stage, allowing greater predictability, less surgical time and were imported into the virtual surgical planning software
(Dolphin 3D, Chatsworth, USA), which generated the
three-dimensional data in STL file format. Then, in the
software Blender 3D (Blender Foundation, Amsterdam, the
& Jéferson Martins Pereira Lucena Franco Netherlands), osteotomies were simulated, and virtual
jefersonlucenaodonto@hotmail.com surgical guides were modeled, which were based on the
1
bone surface of the three-dimensional reconstruction.
Department of Oral and Maxillofacial Surgery, Fortaleza
General Hospital, Christus University Center - Unichristus,
Fortaleza, Ceará, Brazil
2
Division of Oral and Maxillofacial Surgery, Unichristus
University Center (UNICHRISTUS), Fortaleza, Brazil
3
Division of Oral and Maxillofacial Surgery, Doctor Leão
Sampaio University Center (UNILEÃO), Juazeiro Do Norte,
Ceará, Brazil

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J. Maxillofac. Oral Surg. (Oct–Dec 2021) 20(4):702–705
3D Positioning and Cutting Guides
The digitally modeled cutting and positioning guides were
exported for aluminum machining. The cranial guide had
the following characteristics: adaptation to the zygomatic
arch and the lateral face of the ankylotic block, presenting,
in the upper portion, four holes for 1.5 mm screws that
coincide with the definitive cranial component of the future
articular prosthesis and a lower rod that prevents the
rotation of the guide during installation, and offers an
intermediate space which will determine the height and
extent of the upper limit of the osteotomy (Fig. 1). Like-
wise, the mandibular guide design allows anatomical
adaptation to the lateral face of the mandibular ramus with
eight holes for 2.0 mm screws that match the holes in the
definitive mandibular component. The upper limit of this
guide was determined after the identification of the
mandibular foramen, aiming to preserve the lower alveolar
nerve (Fig. 2).
Fig. 1 Cranial surgical guide drawing based on the bone surface of
three-dimensional reconstruction. An upper shaft with four 1.5 mm
screws (arrow) and a lower shaft (asterisk) guide the height and extent
703
Surgical Technique
Prior to the surgical approach, the patient with TMJ
ankylosis was submitted to prophylactic embolization of
the ipsilateral maxillary artery, as described by Hos-
sameldin et al. [4]. Subsequently, after nasotracheal intu-
bation using nasofibroscopy, the joint was accessed
through an endaural and submandibular incision with dis-
section by planes until exposing the ankylotic block and the
mandible ramus[1]. After exposure, the prefabricated cut-
ting guides were installed on the zygomatic arch and the
mandibular ramus, and temporarily fixed with screws
(Fig. 3). The guided osteotomies were performed with
piezoelectric saw, and then the ankylotic block was care-
fully removed. This was followed by the planing of the
mandibular fossa for a correct adaptation of the cranial
component of the definitive prosthesis. The definitive
components were then placed on the base of the skull and
in the mandibular ramus and fixed in the position previ-
ously determined by the guides (Fig. 4). There was no need
for maxillomandibular block, avoiding transoperative
communication with the oral cavity.
of the osteotomy, which must be completed with a minimum distance
of 0.5 mm from the external auditory canal
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704 J. Maxillofac. Oral Surg. (Oct–Dec 2021) 20(4):702–705

Fig. 2 Mandibular surgical guide drawing based on the bone surface should be performed with a minimum distance of 10 mm from the
of three-dimensional reconstruction of the mandible ramus (arrow). foramen of the mandible. This minimizes the risk of neural damage
The lower limit of the osteotomy in the ankylotic block (asterisk)

Fig. 3 Intraoperative view of the cutting guides and positioning of the cranial and mandibular components, enabling the reproduction of the
planned cuts virtually

The use of cutting guides and 3D positioning proved to

be effective to aid the treatment of temporomandibular
joint ankylosis with a total custom prosthesis in a single
stage, allowing greater predictability, less surgical time and
less morbidity.

Declarations

Conflicts of interest We have no conflicts of interest.

Ethics Approval Ethics approval was not required. The patient has
permitted the images use.

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