Int. J. Oral Maxillofac. Surg.

2015; 44: 10271033

http://dx.doi.org/10.1016/j.ijom.2015.05.003, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Temporomandibular joint C. E. Anyanechi

Oral and Maxillofacial Unit, Department of
Dental Surgery, University of Calabar
Teaching Hospital, Calabar, Nigeria

ankylosis caused by condylar

fractures: a retrospective
analysis of cases at an urban
teaching hospital in Nigeria
C.E. Anyanechi: Temporomandibular joint ankylosis caused by condylar fractures: a
retrospective analysis of cases at an urban teaching hospital in Nigeria. Int. J. Oral
Maxillofac. Surg. 2015; 44: 10271033. # 2015 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Mandibular condylar fractures are common presentations to hospitals

across the globe and remain the most important cause of temporomandibular joint
(TMJ) ankylosis. This study aimed to analyze cases of mandibular condylar fracture
complicated by TMJ ankylosis after treatment. A 16-year retrospective analysis was
performed at the dental and maxillofacial surgery clinic of the study institution;
patient data were collected from the hospital records and entered into a pro-forma
questionnaire. It was found that 56/3596 (1.6%) fractures resulted in TMJ ankylosis.
The age of patients with ankylosis ranged from 12 to 47 years. The age (P = 0.03)
and gender (P = 0.01) distributions were significant, with most cases of ankylosis
occurring in those aged 1130 years (n = 43/56, 76.8%). Fractures complicated by
ankylosis were intracapsular (n = 22/56, 39.3%) and extracapsular (n = 34/56,
60.7%). Ankylosis increased significantly with the increase in time lag between
injury and fracture treatment (P = 0.001). Ankylosis was associated with
concomitant mandibular (85.7%) and middle third (66.1%) fractures. Treatment
methods were not significantly related to ankylosis (P = 0.32). All cases of
Key words: mandible; condyle; fracture
ankylosis were unilateral, and complete (n = 36, 64.3%) and incomplete ankylosis temporomandibular joint; ankylosis.
(n = 20, 35.7%) were diagnosed clinically. The incorporation of computed
tomography scans and rigid internal fixation in the management of condylar Accepted for publication 5 May 2015
fractures will reduce ankylosis. Available online 23 May 2015

Temporomandibular joint (TMJ) ankylo- paired mastication, digestion, speech, ap- stage of early childhood.4 From a surgical
sis is a debilitating condition and most pearance, and oral hygiene.13 It is a perspective, ankylosis is not only chal-
often has an adverse effect on quality of challenging clinical and social problem, lenging to treat technically, but in chil-
life in those afflicted, as it results in im- and often starts during the active growth dren, the surgeon must also consider the

0901-5027/0801027 + 07 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1028 Anyanechi
potential effects of time and growth on the
outcome of the procedure.
When compared with other aetiologies,
the condition is most commonly associated
with trauma (13100%), particularly to the
mandibular condyle; fractures of the man-
dibular condyle constitute 2535% of all
mandibular fractures.5,6 As a result of an
improved understanding of the manage-
ment of condylar fractures, the incidence
is decreasing in developed countries, but it
is still relatively high in most third world
countries, particularly Nigeria where con-
founding variables associated with the
management of these fractures adversely
affect treatment outcomes.7,8
Consequently, because mandibular
fractures are a common occurrence, man-
dibular condylar fractures are frequent
presentations to hospitals across the globe
and remain the most important cause or
predisposing factor to the development of
TMJ ankylosis.36 From the existing liter-
ature, several studies have reviewed vari-
ous aspects of TMJ ankylosis with more
emphasis placed on treatment, but few
have evaluated the role played by mandib-
ular condylar fractures and the resulting
consequences in the propagation of this
condition. Therefore, for the improved
management of condylar fractures and
prevention of TMJ ankylosis due to con-
dylar fracture, the consequences of these
fractures were examined retrospectively,
for a 16-year period, in a tertiary hospital
in Nigeria.
Materials and methods
This was a retrospective study of patients
who sustained fractures of the mandibular
condyle that were complicated by TMJ
ankylosis after treatment was undertaken.
The subjects presented to the oral and
maxillofacial surgery clinic of the study
institution in Calabar, Nigeria, between
June 1996 and May 2012. The study
was exempted from ethical clearance by
the research and ethics committee of the
institution.
Cases with complete data were included
in the study, whereas cases with incom-
plete data were excluded. The condylar
fractures studied were categorized based
on the classification of Marker et al.,9 with
the following modification: condylar head
and neck fractures were classified as intra-
capsular, while those below the neck were
classified as extracapsular or subcondylar.
The types of radiographic images utilized
to classify fractures were postero-anterior
(PA) of the jaws or skull, two oblique
laterals of the mandible, and Townes
view (axial). The radiographs were certified
as standardized by the Association of Radi-
ologists in Nigeria (Calabar branch). The
images were evaluated by three examiners:
an oral and maxillofacial surgeon who
regularly deals with trauma, a senior resi-
dent in oral and maxillofacial surgery trau-
matology, and a traumatology radiologist.
For the diagnosis of condylar fractures, the
examiners were given three options to
choose from: (1) fracture, (2) no fracture,
and (3) uncertain.
The criteria for the diagnosis of TMJ
ankylosis were the absence of protrusive
movement on the involved side and the
presence of bony consolidation in the
region of the TMJ on postero-anterior
skull, lateral oblique mandible, and TMJ
radiographic views (transcranial). The an-
kylosis that presented was further catego-
rized as follows: (1) Complete: restricted
mouth opening with maximum inter-inci-
sal distance of <0.5 cm; absence of pal-
pable movements or complete immobility
of the joints. (2) Incomplete: restricted
mouth opening, but with a maximum in-
ter-incisal distance of 0.5 cm; partial
mobility of the joints on palpation.
Although computed tomography (CT)
and magnetic resonance imaging (MRI)
are the gold standards in the radiological
diagnosis of mandibular condylar frac-
tures and TMJ ankylosis, non-availability
and unaffordability for the patient preclud-
ed their routine use for the diagnosis of
condylar fractures and TMJ ankylosis in
the study institution during the period
studied.
Information obtained from the hospital
register, case files, and plain radiographs
of the subjects were recorded in a pro-
forma questionnaire. The information
recorded were age, gender, type of condylar
30
26
25
20 19
17
15
13
10
7
5 5
5 4
3
0
11 --20 21 - 30 31 - 40
Fig. 1. Age and gender distributions of patients with TMJ ankylosis (age: x2 = 147.376, df = 8,
P = 0.03; gender: x2 = 147.376, df = 8, P = 0.01).
fracture, displacement or no displacement
of the fractured condylar fragment, and
the presence of concomitant mandibular
and midfacial fractures. Other factors
considered were the time lag between
injury and treatment of the fracture, meth-
ods of fracture treatment, and types of
ankylosis that developed. The data
obtained were analyzed using Epi Info
7, 2012 software (US Centers for Disease
Control and Prevention, Atlanta, GA,
USA). For analysis, simple frequency
charts, descriptive statistics, and tests of
significance were used. P-values of <0.05
were considered significant.
Results
A total of 3337 patients with 3596 condy-
lar fractures were included in this study,
and 56/3596 (1.6%) fractures were com-
plicated by TMJ ankylosis after treatment.
The age and gender distributions of the
patients are shown in Fig. 1. There were 41
males and 15 females, giving a male to
female ratio of 2.7:1. The males outnum-
bered the females in all age categories.
The gender (P = 0.01) and age (P = 0.03)
distributions were significant. The age of
patients with TMJ ankylosis ranged from
12 to 47 years (mean 31.4  2.3 years).
More cases of ankylosis was recorded in
those aged 1130 years (n = 43/56,
76.8%) compared to those aged 3150
years (n = 13/56, 23.2%).
Road traffic accidents (RTA) were the
major (n = 49/56, 87.5%) cause of frac-
tures that resulted in ankylosis, while as-
sault was the cause in the remainder
(n = 7/56, 12.5%). The types of condylar
fracture involved were intracapsular
(n = 22/56, 39.3%) and extracapsular or
Male
Female
Total
Linear (Total)
8
4
1
41 - 50
 Condylar fractures and TMJ ankylosis 1029

The methods of treatment were not

Fig. 2. Time lag in weeks between injury and treatment of condylar fractures (x2 = 206, df = 12,
P = 0.001).
subcondylar (n = 34/56, 60.7%). The
number of TMJ ankylosis cases increased
with the increasing time lag between inju-
ry and fracture treatment, and this was
significant (P = 0.001) (Fig. 2).
The distribution of ankylosis according
to the types of condylar fracture and con-
comitant mandibular fractures are shown
in Table 1. Those with intracapsular frac-
tures and displaced condylar segments
were found to be more prone to ankylosis
than those with extracapsular (subcondy-
lar) and undisplaced fractures. Of those
with ankylosis, this was associated
with concomitant mandibular fractures
in 85.7% (48/56); 14.3% (8/56) had
no concomitant mandibular fractures.
Symphysis/angle and symphysis/para-
symphysis/body fracture combinations
resulted in more ankylosis than the other
concomitant mandibular fracture combi-
nations.
Table 2 shows the distribution of an-
kylosis according to concomitant frac-
tures of the midfacial bones. Thirty-
seven of the 56 cases (66.1%) had these
concomitant fractures associated with
TMJ ankylosis; 19/56 (33.9%) cases
occurred without their involvement.
Furthermore, a greater number of sub-
jects were recorded with fracture com-
binations of Le Fort I, II, III, nasal
(n = 6/37, 0.3%) and Le Fort II, III, nasal
(n = 6/37, 0.3%).
significantly related to ankylosis
(P = 0.32) (Fig. 3). The methods of
treatment of the fractures were by soft
diet and jaw exercises (n = 14, 25.0%)
and maxillomandibular fixation (MMF)
and jaw exercises (n = 42, 75.0%). The
MMF was released on postoperative
days 10 (n = 16, 28.6%) and 14
(n = 26, 46.4%).
The mean follow-up period after the
treatment of fractures was 25.3  7.8
months (range 4 weeks to 6.2 years).
The diagnosis of TMJ ankylosis was made
between 7 and 28 months (mean
19.6  3.4 months) after treatment of
the condylar fractures. All cases of anky-
losis were unilateral: 29/56 right (51.8%)
and 27/56 left (48.2%). Clinically, com-
plete (n = 36, 64.3%) and incomplete
(n = 20, 35.7%) ankylosis presented for
assessment and diagnosis. Figures 5 show
the progression of condylar fractures to
TMJ ankylosis after treatment.
Discussion
In this study it was found that TMJ anky-
losis occurred in certain subjects follow-
ing the treatment of mandibular condylar
fractures caused by RTA and assault, and
that cases of ankylosis increased with
decreasing age, a longer time lag between
injury and treatment of condylar fractures,
intracapsular and displaced condylar frac-
tures, and when there were concomitant
mandibular and midfacial fractures. The
age at which the condylar fracture was

Table 1. fractures of the mandible.

No ankylosis Ankylosis Total
Type of fracture
Number % Number % Number %
Site
Intracapsular 568 96.3 22 3.7 590 100
Extracapsular 2613 98.7 34 1.3 2647 100
Displacement of fragment
Displacement 1561 97.4 41 2.6 1602 100
No displacement 1720 99.1 15 0.9 1735 100
Concomitant fracture
Not present 462 98.3 8 1.7 470 100
Present 2819 98.3 48 1.7 2867 100
Distribution of concomitant fractures
Symphysis/angle 463 16.2 13 0.4 476 16.6
Symphysis/parasymphysis/body 503 17.5 11 0.4 514 17.9
Symphysis/body/angle 312 10.9 8 0.3 320 11.2
Parasymphysis/body 327 11.4 6 0.2 333 11.6
Symphysis/body 385 13.4 3 0.1 388 13.5
Angle 182 6.4 2 0.1 184 6.5
Symphysis 109 3.8 3 0.1 112 3.9
Angle/body 78 2.7 1 0.1 79 2.8
Body 236 8.2 1 0.0 237 8.2
Parasymphysis/angle 224 7.8 1 0.0 225 7.8
Total 2819 98.3 48 1.7 2867 100
1030 Anyanechi

Table 2. Distribution of TMJ ankylosis according to concomitant fractures of the middle third of the facial bones.
No ankylosis Ankylosis Total
Number % Number % Number %
Concomitant fracture
Not present 1549 98.8 19 1.2 1568 100
Present 1732 97.9 37 2.1 1769 100
Distribution of concomitant fractures
Type of fracture
Le Fort I, II, III, nasal 195 11.0 6 0.3 201 11.4
Le Fort II, III, nasal 188 10.6 6 0.3 194 11
Le Fort I, II, zygomatic complex 166 9.4 5 0.3 171 9.7
Le Fort I, II, III 104 5.9 5 0.3 109 6.2
Zygomatic complex 172 9.7 4 0.2 176 9.9
Le Fort I, II 293 16.6 3 0.2 296 16.7
Le Fort I, II, nasal 219 12.4 3 0.2 222 12.5
Le Fort I 321 18.1 2 0.1 323 18.2
Zygomatic arch 26 1.5 2 0.1 28 1.6
Nasal 48 2.7 1 0.1 49 2.8
Total 1732 97.9 37 2.1 1769 100

sustained was linked to the complication
of TMJ ankylosis.
Earlier researchers have stated emphat-
ically that the younger the age of the
patient, the greater the chance of this
complication occurring.1,2 The rich vas-
cularized lamellar bony structures in ado-
lescents and young adults with greater
growth and reparative potential are more
prone to developing complications than
the sclerotic lamellar bony structures in
mature adults.14 The chances of ankylo-
sis are greater when fractures are sus-
tained around and within the TMJ
complex, as issues associated with the
healing process predispose such injuries
to complications.7,1013 The issues of
delayed treatment for whatever reason(s),
intracapsular and displaced condylar
fractures, and concomitant mandibular
fractures leading to poor treatment out-
comes for condylar fractures, have also
been emphasized as factors predisposing
to TMJ ankylosis.7,10,11
Consequently, the prevalence obtained
in this study may be attributed to the
Fig. 3. Distribution of the methods of treatment of fractures with ankylosis (x2 = 12.4, df = 8,
P = 0.32).
condylar fractures not being diagnosed
and treated early, and treatment concen-
trated on other fractures of the mandible
and midfacial bones, coupled with insuf-
ficient jaw exercises after the release of
MMF that might have followed. It has also
been stated in a recent study in this envi-
ronment that patients do not seek early
dental care, which may be the reason for
the delayed treatment.14 Consequently, it
is possible that some patients who did
develop ankylosis were not identified be-
cause they did not return for clinical eval-
uation and diagnosis. All of these factors
acting in isolation, or together with the
genetic disposition of the patient, may
have been responsible for the prevalence
of TMJ ankylosis obtained in this study.
He et al.,15 in a retrospective study,
recorded 51 cases of TMJ ankylosis due
to condylar fractures over a period of 3
years but did not relate their finding to the
total condylar fractures that presented
within the period. Xiang et al.16 recorded
a prevalence of 4.2% TMJ ankylosis
caused by condylar fractures in another
retrospective analysis, within a period of
10 years.
As a result of the prevalence obtained in
this study (56/3596, 1.6%) it is certain that
the majority of the condylar fractures did
not result in TMJ ankylosis. There is
evidence to suggest that trauma to the
condyles may result in an intra-articular
haematoma, leading to fibrosis, excessive
bone formation, hypomobility of
the TMJ, and ultimately to ankylosis
of the joint.10,11 Some researchers have
also emphasized that intra-articular hae-
matoma alone can lead to ankylosis of the
TMJ based on the organization and sub-
sequent ossification of an intra-capsular
haematoma.12,13,1517 However, Oztan
et al.18 noted that trauma causing haemor-
rhage in the joint space may not give rise
to ankylosis, as it does not always prog-
ress to form bone. Furthermore, in another
study carried out earlier, ankylosis was
conceptually regarded as the fusion of two
approximated and injured bony surfaces,
and as inappropriate tissue differentiation
after fracture.12
When condylar fractures occur, they
are often associated with concomitant
fractures of other parts of the mandible,
which leads to an increase in the mandib-
ular arch. This increase in size of the
mandibular arch has been shown to be
associated with the development of TMJ
ankylosis.1921 In the present study, the
majority of the patients with ankylosis
had concomitant mandibular fractures
(85.7%; 48/56). This is similar to the
report of Xiang et al.,16 who recorded
associated anterior mandibular fractures
in 13/16 (81.3%) of their patients. Also
from the existing literature, and as found
in the present study, an intracapsular con-
dylar fracture, which destroys both the
condylar head and the surrounding soft

Fig. 4. Incomplete TMJ ankylosis. (A) The patient on presentation. (B) Postero-anterior skull
radiograph of the same patient showing a right subcondylar fracture and concomitant fractures of
the right mandibular angle and left parasymphysis. (C) Postero-anterior skull radiograph 12
months after treatment. (D) TMJ view at 22 months after treatment showing radio-opacity
around the right TMJ.
tissues more severely than other types of
condylar fracture, is the most dangerous
cause of ankylosis due to damage to car-
tilage, displaced or disrupted discs, hae-
matoma formation, and subsequent
fibrosis and calcification in the joint.20,21
The meniscus within the joint acts as a
barrier to prevent fusion of the condyle
with the glenoid fossa.22 If it is damaged,
the condyle and glenoid may fuse if the
body surfaces are also damaged and there
is a haematoma between them, like when
fracture dislocation is accompanied by
displacement of the meniscus from the
glenoid fossa, direct bone-to-bone con-
tact, and close approximation of the artic-
ular components.21
Ferretti et al.13 studied the morphology
of the joints in TMJ ankylosis patients
Condylar fractures and TMJ ankylosis
using coronal CT and noted that a medial-
ly dislocated condyle fracture was more
likely to cause TMJ ankylosis than other
condylar fractures. In the study by Xiang
et al.,16 TMJ ankylosis was recorded only
in fractures affecting the head and neck of
the condyles, whereas no case involved
subcondylar fractures. This is contrary to
the present study, as cases of TMJ anky-
losis were recorded in both intracapsular
and subcondylar (extracapsular) fractures.
He et al.23 concluded that the combination
of an intracapsular condylar fracture with
concomitant widening of the mandible
leads to the lateral pole of the condyle
or the condylar stump becoming displaced
laterally or superolaterally in relation to
the zygomatic arch, where it fuses result-
ing in ankylosis.
1031
Xiang et al.16 suggested that the tech-
nique used for the fixation of condylar
fractures was important in determining
whether there will be TMJ ankylosis or
not. They noted that long-screw (bicorti-
cal screw) fixation of fractures of the
condylar head seemed to be associated
with a lower incidence of postoperative
ankylosis than fixation by miniplate and
wire or removal of the fractured fragment.
In contrast, the methods of treatment in
the present study were not significantly
related to the treatment outcome, and
consequently the complication of TMJ
ankylosis.
There were no patients with TMJ anky-
losis under age 11 years. Facial fractures
in children are relatively uncommon, and
this is probably due to the elasticity of the
paediatric bone.24,25 Dahlstrom et al.,26 in
a 15-year follow-up on condylar fractures
after treatment, stated that complications
are lower in children than in adults. How-
ever, children below the age of 11 years
are more prone to TMJ ankylosis.1,4
This study was limited by the use of
only plain radiographic views; no CT
scans or MRI techniques were employed
in the diagnosis of the condylar fractures
and the TMJ ankylosis. The plain radio-
graphs are the main drawback, as the
mandibular condyle is difficult to visualize
on these plain views due to overlapping of
the adjoining anatomical structures.24,25
Consequently, there was no distinction
between displacement, dislocation, and
sagittal fractures of the condyle, the extent
of injury to the meniscus and its position
and relation to the condyle and glenoid
fossa, which are very important criteria for
ankylosis. Also rigid internal fixation was
not utilized for the treatment of the frac-
tures, particularly the displaced fractured
segments, because this method of treat-
ment was not available in the study centre
during the study period.
This study showed that post-traumatic
TMJ ankylosis occurred in certain subjects
with condylar fractures after treatment.
The major factors found to be associated
with TMJ ankylosis were decreasing age,
increase in time lag between injury and
treatment of the condylar fracture, intra-
capsular and displaced condylar fractures,
and concomitant mandibular and midfa-
cial fractures. However, the incorporation
of CT scans, MRI techniques, and rigid
internal fixation in the management of
condylar fractures, following the trend
in contemporary oral and maxillofacial
surgical practice, will improve patient
wellbeing in the postoperative period
and enhance the treatment outcome, re-
ducing TMJ ankylosis.
1032 Anyanechi
Fig. 5. Complete TMJ ankylosis. (A) The patient on presentation. (B) Postero-anterior skull
radiograph of the same patient showing intracapsular condylar fractures. (C) Postero-anterior
skull radiograph of the same patient 10.5 months after treatment. (D) TMJ view at 19 months
after treatment showing radio-opacity around the right TMJ.
Funding
None; the study was self-funded.
Competing interests
There is no competing interest.
Ethical approval
This study was exempted from the need
for ethical approval.
Patient consent
Written patient consent was obtained to
publish clinical photographs.
Acknowledgements. I wish to express my
sincere gratitude to Mrs Adiaha Ofem of
the Department of Health Records and
Information Management, University of
Calabar Teaching Hospital, for her assis-
tance in sorting out the case files of the
subjects.
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