BACKGROUND: Skeletal ankylosis of the temporomandibular joint (TMJ) can have debilitating consequences. We present an institutional experience of the surgical treatment of TMJ ankylosis in pediatric patients with craniofacial microsomia.
METHODS: Patients with TMJ ankylosis and craniofacial microsomia treated at our institution between 1976 and 2019 were identified through retrospective chart review including clinical records, operative reports, and imaging studies. Data collected included demographics, Pruzansky classification, TMJ ankylosis, surgical operations (mandibular procedures, tracheostomy, gastrostomy), and postoperative outcomes including re-ankylosis.
RESULTS: TMJ skeletal ankylosis was diagnosed in 15 patients (8 bilateral). Mean age at diagnosis was 6.7 (range, 0–18 years). Three cases of TMJ ankylosis were congenital and 12 were iatrogenic, occurring during the treatment of craniofacial microsomia (Pruzansky IIB: n = 5; III: n = 7). Ankylosis developed after distraction osteogenesis in 8 patients (2 of whom had been referred from other institutions) or after autologous mandibular reconstruction in 4 patients. Follow-up was 12.6 ± 6.6 years. On average, patients had 9 (range, 2–19) mandibular operations. Adjusting for length of follow-up, patients having their first mandibular operation at a younger age had more frequent reoperations. Mandibular reconstruction involved costochondral grafts in 4 patients, iliac crest in 1, and microvascular free fibula transfer in 2. Gap arthroplasties were performed in 9 patients, interpositional arthroplasties in 5, and coronoidectomies in 7. One patient underwent alloplastic joint replacement. Overall improvement in mean interincisal opening was 24.8 ± 6.4 mm. Ankylosis recurred in 73.3% of cases (3 congenital and 8 iatrogenic) and necessitated on average 3 operations (range, 1–8). Tracheostomy dependence persisted in 6 (40%) patients and gastrostomy dependence persisted in 7 (46.7%). Decannulation was successful in 5 patients. Recurrence of bilateral ankylosis necessitated repeat tracheostomy in 1 patient. Tracheostomy was successfully prevented in 3 patients.
CONCLUSION: TMJ ankylosis in the setting of craniofacial microsomia reconstruction is associated with high recurrence rates requiring multiple reoperations, despite improvement in initial postoperative mean interincisal opening. In patients with craniofacial microsomia, younger age at initial mandibular surgery and number of operations seem to be associated with an increased risk of TMJ ankylosis and tracheostomy and gastrostomy dependence.