J Oral Maxillofac Surg

69:2412-2418, 2011

Surgical Treatment of Traumatic

Temporomandibular Joint Ankylosis With
Medially Displaced Residual Condyle:
Surgical Methods and Long-Term Results
Dongmei He, DDS, MD, PhD,* Chi Yang, DDS, MD, PhD,
Minjie Chen, DDS, MD, PhD, Xiujuan Yang, DDS, MS,
Lingzhi Li, DDS, MS, and Qian Jiang, DDS, MS

Purpose: We report a surgical method for the treatment of traumatic temporomandibular joint (TMJ)
ankylosis with a medially displaced residual condyle and compare the long-term results with those
obtained using different interpositional materials.
Patients and Methods: From 2001 to 2009, 60 patients and 82 joints diagnosed with traumatic TMJ
ankylosis with a medially displaced residual condyle were included in the present study. Lateral
arthroplasty (LAP) was performed, and either the masseter muscle flap (MMF) or the temporalis
myofascial flap (TMF) was used as interpositional material to fill the lateral space. The long-term results
of these treatments were compared by performing postoperative computed tomography scans and
clinical follow-up examinations.
Results: Of the 82 joints, 22 were treated with LAP, 28 with LAP and MMF, and 32 with LAP and TMF.
Of the 60 patients, 38 (48 joints) participated in long-term follow-up (from 1 to 4 yr). Of the 11 joints
treated with LAP, 4 (36.4%) developed reankylosis. Of the 17 joints treated with LAP and MMF, 3 (17.6%)
developed reankylosis, and none of the 20 joints treated with LAP and TMF developed reankylosis.
Compared with LAP alone, LAP with TMF significantly improved the maximal incisal opening during
long-term follow-up.
Conclusion: LAP can preserve the residual TMJ structure. The TMF is a reliable interpositional material
in LAP for the prevention of reankylosis.
2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:2412-2418, 2011

Temporomandibular joint (TMJ) ankylosis is a refrac-
tory disease that limits mouth opening and causes
facial deformities when it occurs during the growing
years. Trauma is the main cause of TMJ ankylosis and
accounts for 75% to 98% of all cases.1-5 According to
the results of our previous study, 2 types of traumatic
bony ankylosis exist. In 1 type of TMJ ankylosis, the
residual condylar fragment is located on the medial
side of the joint and bony fusion is present on the
lateral side. Alternatively, in the other type of trau-
matic bony ankylosis, bony fusion is present on the
joint and a residual condyle is not observed.6 Accord-
ing to the published data, ankylosis can be treated by
gap arthroplasty, interpositioning arthroplasty, and
TMJ reconstruction with autogenous or alloplastic
materials. Aggressive excision of the fibrous and/or

Received from Department of Oral and Maxillofacial Surgery, Ninth Returned Overseas Chinese Scholars, State Education Ministry; and
Peoples Hospital, Shanghai Jiao Tong University School of Medi- Program for Innovative Research Team of Shanghai Municipal Ed-
cine, Shanghai Key Laboratory of Stomatology, Shanghai, China ucation.
*Associate Professor. Address correspondence and reprint requests to Dr Yang: De-
Professor. partment of Oral and Maxillofacial Surgery, Shanghai Ninth Peo-
Associate Professor. ples Hospital, Shanghai Jiao Tong University School of Medicine,
Resident. 639 Zhi Zao Ju Rd, Shanghai 200011, China; e-mail: yangchi63@
PhD Student. hotmail.com
PhD Student. 2011 American Association of Oral and Maxillofacial Surgeons
This work was supported by the Science and Technology Com- 0278-2391/11/6909-0026$36.00/0
mission of Shanghai (grant 08DZ2271100); the Foundation for doi:10.1016/j.joms.2011.04.001

2412
HE ET AL
bony ankylotic mass with either distraction osteogen-
esis or a costochondral graft and rigid fixation for the
reconstruction of the ramus condyle unit is an ac-
cepted management protocol and has been recom-
mended by Kaban et al.7 Nevertheless, we attempted
to keep the medially displaced residual condyle and
remove the lateral bony fusion. We termed this pro-
cedure lateral arthroplasty (LAP). This method was
recommended by Nitzan et al8 in 1998 and was per-
formed on 4 patients. The results of the previous
study suggested that the displaced condyle and disk
should be retained to promote normal function and
growth. The capsule lateral was sutured to the joint to
cover the resection site and prevent reankylosis. Nev-
ertheless, we used this method in our early treatment
group and found a high rate of reankylosis. To pre-
vent reankylosis, the temporalis myofascial flap (TMF)
or the masseter muscle flap (MMF) was used to fill the
lateral space. In the present report, we describe the
proposed surgical method and the long-term results of
LAP and LAP with different interpositional materials,
for the treatment of traumatic TMJ ankylosis with
medially displaced residual condyle. We hypothesized
that the proposed operative technique and a suitable
interpositional graft could improve the mandibular
range of motion.
Patients and Methods
The present investigation was a retrospective study
and was approved by the local ethics board. Patients
diagnosed with TMJ ankylosis and medially displaced
residual condylar fragments due to trauma from 2001
to 2009 were included in the present study. Before
surgery, a computed tomography (CT) scan with cor-
onal reconstruction was conducted on the TMJ area
to guide the surgery. For all patients, LAP was per-
formed according to the surgical method described
below. A TMF or MMF was used as the interpositional
material on some of the patients.
The patients were divided into 3 groups according
to the treatment method: LAP, LAP with a MMF, and
LAP with a TMF. The treatment results were evaluated
by conducting postoperative CT scans and clinical
follow-up examinations. When bony fusion was ob-
served in the lateral space between the ramus and
fossa on the CT coronal reconstruction from the TMJ
area, reankylosis was diagnosed. TMJ function was
measured by determining the maximal incisal open-
ing (MIO) during follow-up.
SURGICAL METHOD
A modified preauricular approach was used to pro-
tect the superficial and middle temporal vessels.9 The
temporal branch of the facial nerve should be care-
fully protected during dissection. After exposure of
2413
the bony mass, the laterally protruded portion of the
bony mass was removed with an oscillating saw (Fig
1A). At this point, the bony fusion mark between the
ramus stump and glenoid fossa was visible (Fig 1B),
and the second osteotomy line was made along the
mark with an oscillating saw. The third osteotomy
line was made oblique to the ramus, and the ankylotic
mass was removed (Fig 1C,D). When making the
second and third osteotomy lines, the cutting length
and direction were determined by conducting a CT
scan with TMJ coronal reconstruction (Fig 2A). To
prevent damage to the inner condylar segment and
disk, care should be taken not to cut too deep. After
removing the ankylotic mass, the mandible was re-
leased from the skull base (Fig 1E). The remainder of
the stump and glenoid fossa were contoured with a
bur (Fig 1F). The disk was released and sutured with
a TMF or MMF to fill the lateral bone resection space
(Fig 1G). An intraoperative MIO of 40 mm should be
achieved. If the MIO was less than 40 mm, a coronec-
tomy was conducted on the ankylotic and/or con-
tralateral side.
FOLLOW-UP EVALUATION
The MIOs before and after each treatment were
compared by conducting long-term follow-up studies.
Statistical analysis was performed using the Statistical
Package for Social Sciences, version 13.0 (SPSS, Chi-
cago, IL). The Student paired t test was used to estab-
lish intragroup (before and after treatment) signifi-
cance, and nonparametric tests on k independent
samples, and Kruskal-Wallis H tests were used to
determine the significance of intergroup MIO im-
provement. An level of 0.05 was considered
significant.
Results
A total of 60 patients and 82 joints were evaluated.
Patient age ranged from 3 to 72 years (mean 20). Of
the 60 patients, 28 were females and 32 were males;
they presented with a preoperative MIO of 0 to 20
mm (mean 6.76). The mean preoperative MIO for
each treatment group was as follows: LAP, 6.67 mm;
LAP plus MMF, 7.15 mm; and LAP plus TMF, 6.5 mm.
Significant differences among the 3 groups were not
observed (P .05). Bilateral LAP was conducted on
22 patients, and 38 patients underwent unilateral
LAP. Of the 82 joints, 22 were treated with LAP, 28
with LAP and MMF, and 32 with LAP and TMF (Table
1). All patients acquired a 40-mm intraoperative MIO.
The postoperative CT scan revealed that the lateral
bony fusion had been completely removed and the
residual condyle remained intact (Fig 2B). After sur-
gery, 2 patients with bilateral TMJ ankylosis devel-
2414 SURGICAL TREATMENT OF TRAUMATIC TMJ ANKYLOSIS

FIGURE 1. Surgical procedure of LAP. A, Laterally protruding portion of bony mass removed with oscillating saw. B, Bony fusion mark
between ramus stump and glenoid fossa visible. C, Second and third osteotomy lines made with oscillating saw. D, Lateral bony mass
completely removed. (Figure 1 continued on next page.)
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral Maxillofac Surg 2011.
HE ET AL 2415

FIGURE 1 (contd). E, Mandible released from skull base. F, Rest of stump and glenoid fossa contoured with bur. G, Disk released and
sutured with TMF to fill lateral wedge space.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral Maxillofac Surg 2011.
2416 SURGICAL TREATMENT OF TRAUMATIC TMJ ANKYLOSIS

Table 2. TREATMENT AND RESULTS OF

TMJ ANKYLOSIS

Recurrence/ Postoperative
Treatment Patients (n) Follow-up (%) MIO (mm)

LAP 22 4/11 21.22

LAP MMF 28 3/17 28.15
LAP TMF 32 0/20 30.75
Total 82 (100%) 7/48 (14.5%) P .05
Abbreviations as in Table 1.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral
Maxillofac Surg 2011.

with LAP, 3 (17.6%) of the 17 treated with LAP and

FIGURE 2. CT scans of TMJ coronal reconstruction on patient with
bilateral bony ankylosis. A, Preoperative CT scan of coronal recon-
struction revealed presence of bilateral TMJ bony ankylosis with
medially displaced residual condylar fragments. B, Postoperative
CT scan of coronal reconstruction after LAP showed lateral bony
mass completely removed and intact residual condyle.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral
Maxillofac Surg 2011.
oped an open bite, which was corrected by perform-
ing elastic traction for 2 months.
Of the 60 patients, 38 (48 joints) participated in the
long-term follow-up study (1 to 4 years). Reankylosis
was observed in 4 (36.4%) of the 11 joints treated
MMF, and 0 (0%) of the 20 treated with LAP and TMF.
CT scans of the patients with reankylosis revealed that
bony fusion was present in the lateral space. The MIO
of these patients was less than 10 mm. During long-
term follow-up care, the mean MIO after treatment
was as follows (1 to 4 years): LAP, 21.22 mm; LAP
with MMF, 28.15 mm; and LAP with TMF, 30.75 mm.
Significant differences in the MIO of each group was
not observed before and after treatment. The change
in the MIO with the 3 treatment methods was com-
pared. The results indicated that LAP with TMF sig-
nificantly improved the MIO (P .032 vs P .05;
Table 2). In several patients who were still growing,
the ramus of the ankylosed side grew and was remod-
eled (Figs 3, 4).
Discussion
Surgical treatment of TMJ ankylosis includes resec-
tion of the ankylosed joints and coronoid processes
and the detachment of the pterygomasseteric slings,
ligamentous attachments, and fibrous adhesions be-
tween the skull base and mandible.7 Three methods
have been developed to correct ankylosed joints, in-
cluding gap arthroplasty, interpositional arthroplasty,
and TMJ reconstruction. In the present study, instead
of resection of the ankylotic mass, the medially dis-

Table 1. GENERAL INFORMATION FOR 3 TREATMENT GROUPS

Treatment Method LAP LAP MMF LAP TMF Total

Patients 18 19 23 60
Mean age (yr) 14.9 25.5 19.9
Gender
Female 9 9 10 82
Male 9 10 13
Joints (n) 22 28 32 P .05
Preoperative MIO (mm) 6.67 7.15 6.50
Abbreviations: LAP, lateral arthroplasty; MMF, masseter muscle flap; TMF, temporalis myofascial flap; MIO, maximal incisal
opening.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral Maxillofac Surg 2011.
HE ET AL
FIGURE 3. CT scans of 11-year-old girl with right TMJ bony ankylosis
treated by LAP. A, Preoperative CT scan indicated right TMJ bony
ankylosis with medially displaced residual condylar fragment. B, CT
scan conducted 6 months after LAP revealed remodeling of right
condyle, ramus, and glenoid fossa. C, CT scan conducted 3.5 years
after LAP showed right ramus and condyle growth.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral
Maxillofac Surg 2011.
2417
FIGURE 4. Photographs of same patient 3.5 years after LAP
treatment. A, Frontal view showing chin slightly deviated to right
side. B, Patients mouth opening 40 mm.
He et al. Surgical Treatment of Traumatic TMJ Ankylosis. J Oral
Maxillofac Surg 2011.
placed condylar segment and disk was maintained to
avoid joint reconstruction using the costochondral
graft, distraction osteogenesis, or total joint prosthe-
sis. The MIO was evaluated by conducting long-term
follow-up. The results suggested that the condyle
functioned well. However, the condyle was located in
an awkward medial position, as hypothesized by Nit-
zan et al.8
Reankylosis is the primary complication of any treat-
ment method. To prevent reankylosis, the dead space
must be eliminated. The results of the present study
showed that the greatest reankylosis rate was obtained
2418
with LAP alone (36.4%). However, when interpositional
material was used, the rate of reankylosis decreased
dramatically. MMF and TMF are often used as autoge-
nous materials to line the joint after resecting an anky-
lotic mass. These materials can be easily harvested from
the same incision and have been reported to have good
results and long-term viability in TMJ surgery.10-13 The
TMF is associated with lower reankylosis rates than the
MMF because the TMF contains fat, which can prevent
heterotopic ossification in the TMJ joint. The results of
an animal study showed that the presence of fat in the
joint space disrupts new bone and cartilage growth.14
The TMF was used in the present study, because it can
be harvested (fascia plus muscle for greater bulk) to fill
dead space, has a good blood supply (inferiorly based
branches of the middle and deep temporal arteries), and
is proximal to the operative site for easy harvesting.10
Compared with LAP alone, the use of TMF can signifi-
cantly improve the MIO.
When bilateral TMJ ankylosis was treated with LAP,
some patients developed an open bite after surgery
owing to the shortened mandibular ramus. Elastic
traction was used to correct the open bite. When this
method was ineffective, sagittal split ramus osteot-
omy was performed.
Several issues require additional clarification, in-
cluding the degree of ramus growth after LAP in
growing patients. Whether these patients will require
additional jaw surgery to correct the jaw bone defor-
mity cannot be determined until growth is complete.
In adult patients with jaw bone deformities, the effect
of simultaneous orthognathic surgery on the outcome
of LAP requires additional study.
In conclusion, LAP can reserve the residual TMJ
structure for function. Moreover, TMF is a reliable
interpositional material that can be used in LAP to
prevent reankylosis.
SURGICAL TREATMENT OF TRAUMATIC TMJ ANKYLOSIS
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