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British Journal of Oral and Maxillofacial Surgery 59 (2021) 820–825
Strategies to reduce re-ankylosis in temporomandibular

joint ankylosis patients
P. Yadav, A. Roychoudhury ∗ , O. Bhutia
Department of Oral & Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India
Available online 20 February 2021
Abstract
The purpose of the study was to define a protocol for the prevention of re-ankylosis after surgical management of temporomandibular joint
ankylosis (TMJA). The investigators designed a retrospective study on all TMJA patients treated with different treatment modalities from 2013
to 2019. The investigators observed that complete removal of the ankylotic mass particularly on the medial side; use of a piezoelectric scalpel
for a clean and smooth osteotomy with copious irrigation to remove bone chips and slurry; less trauma to the local tissue; osteotomy design
parallel and inferior osteotomy at the narrowest part, which mostly corresponds to the condylar neck; performance of a coronoidectomy (if
mouth opening is <30 mm), fat interposition; no intraoperative correction of any pre-existing chin deviation when treated with costochondral
graft; patient motivation; and aggressive physiotherapy, and use of a vacuum drain are all important to prevent re-ankylosis, irrespective of the
treatment modality. A total of 114 patients (n = 152 joints), [bilateral (n = 38), unilateral (n = 76)] were evaluated retrospectively. Interpositional
arthroplasty with fat was performed in n = 43, CCG was used for reconstruction in n = 30 and total joint replacement (TJR) was done in n = 41
patients. Re-ankylosis was seen in n = 3 (2.6%) patients (2 in CCG and 1 patient in interpositional arthroplasty). The follow-up ranged from
12-80 months. The results conclude that following the suggested best practice protocol is effective in reducing re-ankylosis.
© 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Temporomandibular joint ankylosis; Re-ankylosis; Interpositional arthroplasty; Costochondral graft; Total joint replacement
Introduction 11.97% with different treatment modalities.16 A recent study

from Great Ormond Street has observed a re-ankylosis rate
Management of TMJA includes gap arthroplasty,1,2 inter- of 32.7% with CCG.17 Irrespective of the treatment modal-
positional arthroplasty (IA) with different materials [buccal ity, prevention of re-ankylosis is one of the foremost goals.
fat pad (BFP),2,3 abdominal fat (AF),3 fascia,4 dermis- It measures the rate of success of the treatment modality. In
fat,4,5 muscle,6 full thickness skin graft7 and coronoid this paper, the purpose of the investigators was to present a
process8 ] and ramus-condyle unit (RCU) reconstruction with protocol to reduce the chances of re-ankylosis, irrespective
autogenous [costochondral graft9,10 (CCG), sternoclavicu- of the treatment modality.
lar graft,11 transport disc distraction osteogenesis10,12 ] or
alloplastic temporomandibular joint replacement (TJR).13–15
Even with advancements in diagnosis, surgical skills and
instrumentation, the surgical management throws a chal- Material and methods
lenge of re-ankylosis. Re-ankylosis rates vary from 2.56% to
Study design
∗ Corresponding author at: Professor and Head, Room No 111, Depart-
ment of Oral & Maxillofacial Surgery, CDER, All India Institute of Medical A retrospective study was instituted on patients treated for
Sciences, New Delhi, 110029, India. Tel.: +91 9891007749. TMJA between January 2013 and July 2019. The study was
E-mail address: ajoyroy@hotmail.com (A. Roychoudhury). retrospective hence ethical clearance was exempted. Unilat-
https://doi.org/10.1016/j.bjoms.2021.02.007
0266-4356/© 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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02, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
P. Yadav et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 820–825 821
eral or bilateral TMJA patients having follow-up records of

at least 12 months were included irrespective of age, sex,
and treatment modality. Patients with incomplete clinical and
radiological records were excluded. Patients were divided
into 3 groups according to treatment modalities. The first
group included all the patients treated with interpositional
arthroplasty with fat (IA group), the second group included
patients managed with CCG (CCG group) and the third group
included patients managed with TJR (TJR group).
Data was collected retrospectively from the departmental
registry. Assessment of preoperative age, sex, side of ankylo-
sis, and maximal incisal opening (MIO) was done clinically
and radiographically. Follow-up clinical and orthopantomo-
gram or CT SCAN radiographic evaluation was done to
observe HB formation. Follow-up MIO of less than 20 mm
was considered as re-ankylosis.
Study variables
Fig. 1. Showing superior (A) and inferior osteotomy line (B) and (C).
The primary predictor variable was treatment instituted (IA, Osteotomy should be done at (C). This reduces the opposing surface area at
arthrectomy site.
CCG, TJR). The primary outcome variable was re-ankylosis
and secondary outcome variable was MIO. Other variables
like age, sex, side of ankylosis, aetiology, and duration of
ankylosis (DOA) were also recorded.
tion and easy availability from the existing extraoral incision.
Surgical technique The average volume of BFP is 9.6 ml. 7 ml was kept as safe
cut off for filling the defect. The volume of the defect was
Osteoarthrectomy—The standard surgical technique was fol- measured by pouring premeasured saline in a syringe. BFP
lowed for the treatment modalities. Extended preauricular was harvested, if the volume of defect was ≤7 ml. In cases
incision was used to access the ankylotic mass. Osteoarthrec- where the defect was more than 7 ml, AF would be indicated
tomy was performed perpendicular to the cortical bone by for interpositioning. Buccal fat pads were harvested using a
piezoelectric scalpel under copious irrigation with saline. technique described by Roychoudhury et al.3 Blunt dissection
Tapering of the cut was avoided. An inferior osteotomy was was performed anterior and medial to the coronoid process
placed at the narrowest part, if present, (though not always through the same surgical site. Care was taken to not punc-
narrow) when viewed mediolaterally (Fig. 1). This reduced ture through the mucosa to avoid any oral opening and saliva
the surface area of the opposing cut surface. A 1.5–2 cm contamination. External pressure in the temporal and intrao-
gap further reduced any chance of bone formation and re- ral milking action at the region of the tuberosity was applied.
ankylosis. Minimal osteoarthrectomy was avoided as this The fat started popping in the region. It was gently teased out
provided a broader opposing cut surfaces conducive for re- with the help of a vascular clamp. After filling of the recipient
ankylosis. Piezoelectric osteotomy leaves a smooth margin, site, the fat was secured with sutures. In procedures of CCG
any remaining spicule was either smoothed by piezo or or TJR, the fat was packed around the joint.
bone file. Coronoidectomy was performed as per Kaban’s
protocol.18 Ipsilateral coronoidectomy was performed if pas-
sive MIO after osteoarthrectomy was <30 mm. Contralateral
coronoidectomy was performed only if the passive mouth Physiotherapy
opening of >30 mm after ipsilateral coronoidectromy was not
achieved. Physiotherapy, using a tapered acrylic trismus screw started
within 24 hours (h). In the first 8–36-h postoperatively, the
Interposition and reconstruction regimen was 5–6 attempts daily (10–15 insertions per try).
In next 48–96 h, 8–10 attempts daily (20–25 insertions per
The decision for reconstruction was based on the age of try) and thereafter 10–12 attempts daily. The same proce-
the patient and the recurrent nature of the ankylosis. Adult dure was continued for the next 6 months. After 6 months, if
patients (>16year) were reconstructed with TJR. CCG was MIO was smooth and stable without any morning tightness,
used for reconstruction in only previously non-operated pae- then it continued as per the patient’s preference.1 Patients
diatric patients. The choice of interpositioning material was were encouraged to consume foods requiring active biting
fat because of its reported advantages in reducing HB forma- and chewing.
822 P. Yadav et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 820–825
Table 1
Baseline variables and their association with primary outcome variable.
Study variables Descriptive stats Re-ankylosis p value
1 Study sample 114 patients (152 joints) 3 –
2 Study sample in different group TJR 41 (54 joints) 0 (0%) 0.220
CCG 30 2 (6.7%)
IA 43 1 (2.3%)
3 Age 15.75 ± 9.76 years
4 Sex Male 60 1 (1.7%) 0.498
Female 54 2 (3.7%)
5 Side of ankylosis Unilateral 76 1 (1.3%) 0.606
Bilateral 38 2 (5.3%)
6 Aetiology Trauma 87 (76.3%) 2 (2.3%) 0.956
Infection 20 (17.54%). 1 (5.0%)
Ankylosing spondylitis 1 (0.87%) 0 (0%)
Idiopathic 6 (5.26%) 0 (0%)
7 Duration of ankylosis 7.05 ± 6.95 years
8 Follow-up 25.98 ± 15.43 months
TJR, total joint replacement; CCG, costochondral graft; IA, interpositional arthroplasty.
Data analysis follow-up range was 12–48 months)]. The IA group had re-
ankylosis in 1 10-year-old after 10-months follow up (range
Descriptive statistics were performed by calculating the mean 12–80 months). No reason for re-ankylosis could be found
and standard deviation for the continuous variables. Cate- other than probable inconsistent physiotherapy. No associa-
gorical variables were presented as absolute numbers and tion was seen between the primary predictor variable and the
percentage. SPSS (statistical package for social sciences) primary outcome variable (Table 2). A paired t test revealed a
version 25.0 and MedCalc software was used for statisti- statistically significant difference in preoperative and postop-
cal analysis. The chi squared test was used to investigate erative MIO (p value = 0.001) (Table 3). The binary logistic
whether distributions of categorical variables differed from regression analysis showed that none of the variables (age,
one another. Regression analysis was used for estimating the gender, and MIO) had significant effect on the treatment
relationships among variables. Binary logistic regression was outcome (Table 4).
done to see the effect of the predictor variables on the outcome
variable. The p value of <0.05 was taken to be significant at
a confidence interval of 95%.
Discussion
The rate of re-ankylosis measures the success of surgical pro-

Results cedure. Strategies to reduce re-ankylosis are given in Table 5.
Incomplete removal of the ankylotic mass (particularly medi-
The study sample was composed of 114 patients (n = 152 ally), inconsistent physiotherapy, and HB formation are the
joints), (m:f = 1.1:1), (bilateral, n = 38, unilateral, n = 76). factors responsible for re-ankylosis. The factors responsi-
The mean age of the study sample was 15.75 ± 9.76 years ble for the formation of HB are prostaglandin E2, local
(range 3 to 55). Median age was 21 years in TJR group, hypoxia, abnormal nerve activity, activation of mast cells,
9.5 years in the CCG group and 10 years in the IA group. and immobilisation.19,20
Trauma was the main aetiology in n = 87 (76.3%) followed by Preoperative planning to know the extent of the anky-
infection in n = 20 (17.54%). A total of 99 patients had no his- lotic mass is important. A medially displaced condyle should
tory of previous operation (primary), and 15 were recurrent be removed as this acts as a nidus for bone formation and
cases. Mean DOA was 7.05 ± 6.95 years. Mean follow-up re-ankylosis. The osteotomy cut should be parallel. Special
was 25.98 ± 15.43 months (range = 12–80 months). All the care should be taken at the posterior edge because any pro-
study variables with descriptive statistics and their associa- jection can impinge on the temporal bone preventing full
tion with primary outcome variables are given in Table 1. It rotation and less MIO. Conventionally, rotary instruments
was observed that patients with age >16 years, either primary (burr and handpiece) and chisel and mallet are used for
or recurrent were treated by TJR. Non-recurrent paediatric osteoarthrectomy. Rotary instruments can lead to marginal
patients were treated with CCG. There was no re-ankylosis in osteonecrosis by the heat produced during their use. Irreg-
the TJR group (follow-up range 12–65 months). Re-ankylosis ular and rough osteotomy are some of the factors that can
was seen in n = 2 patients (6.7%) in CCG group [(ages 3 and 9 lead to increased chances of re-ankylosis. Early healing of
years, after 12 and 14 months, respectively) (the CCG group the cut bone end is critical in its prevention. A piezoelectric
Table 2
Association between primary predictor variable with primary outcome variable.
Primary predictor variable Re-ankylosis ␹2 value p value
Yes No
TJR 0 41 (100%) 3.03 0.22
CCG 2 (6.7%) 42 (97.7%)
IA 1 (2.3%) 28 (93.3%)
CCG, costochondral graft; TJR, total joint replacement; IA, interpositional arthroplasty.
Table 3
Changes in maximal incisal opening.
Modality Maximal incisal opening Mean Standard deviation Mean difference t test value p value
TJR Preoperative 5.17 6.70 −30.15 −27.387 0.001a
Postoperative 35.32 4.20
CCG Preoperative 3.83 4.22 −28.37 −24.902 0.001a
IA Preoperative 2.84 3.22 −33.07 −39.769 0.001a
All treatment Preoperative 3.94 5.03 −30.78 −50.523 0.001a
a Statistically significant difference; CCG, costochondral graft; TJR, total joint replacement; IA, interpositional arthroplasty.
Table 4
The binary logistic regression analysis showed that none of the variables had significant effect on the treatment outcome.
B S.E. Wald df Sig. Odds ratio 95.0% C.I.
Lower Upper
Mouth opening −0.040 0.084 0.232 1 0.630 0.961 0.815 1.132
Age −0.414 0.242 2.938 1 0.087 0.661 0.412 1.061
Gender 0.819 1.239 0.437 1 0.509 2.269 0.200 25.756
Table 5
Strategies to reduce of re-ankylosis.
Factors to be considered Effects
1 Preoperative assessment of dimension/extent of ankylotic mass •Helps in complete removal of ankylotic mass
•Reduces the potential source of BMP
2 Use of piezoelectric scalpel for osteoarthrectomy and copious •Clean and smooth osteotomy cut (early healing)
irrigation throughout the procedure •Removes bony chips by continuous irrigation with saline
(potential source of BMP)
•Precise cut and less trauma to the tissue (less local hypoxia)
•Less haemorrhage-less haematoma
3 Osteotomy design—parallel and inferior osteotomy at narrowest •Decreases surface area of opposing the cut surface
part which mostly corresponds to condylar neck •Avoids hindrance and provides resistance-free mouth opening
Perform coronoidectomy, if mouth opening is less than 30 mm
4 Fat interposition •Prevents dead space and consequent haematoma and heterotopic
bone formation
•Avoids contact between fossa and mandibular ramus
5 Patient motivation and aggressive physiotherapy •Improves psychological status of patient and motivates for
aggressive physiotherapy
6 No intraoperative correction of pre-existing occlusion and chin •Prevents excessive stress, strain on the functional muscle matrix.
deviation in cases managed with costochondral graft •Prevents micromotion, overgrowth, and consequent re-ankylosis
7 Use of vacuum drain •Prevents formation of hematoma
8 NSAIDsa •Inhibition of prostaglandin E2, Cox 1, and 2
a Not used in the present study; NSAIDs, non-steroidal anti-inflammatory drugs.
824 P. Yadav et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 820–825
scalpel provides microcut, uniform, smooth, clean and safe bone formation at the site. According to Reitzig, CCG does
osteotomy with minimal trauma to soft tissue. The use of a not heal for 6 months even if it is rigidly fixed.28 Any mobility
piezoelectric scalpel for osteoarthrectomy in TMJA patients in the postoperative period can cause micromotion leading
was first reported in 2014.21 Ultrasonic vibrations help in pro- to HB formation. A requirement of immobilisation in the
ducing cavitational energy which removes all the cut debris, postoperative period, when the chances of HB formation are
bony chips, and provides a clean surgical field. These bony greatest, raises a question for CCG being a good option for
chips are a source of bone morphogenetic proteins (BMP).22 TMJ reconstruction. Interposition of fat probably tides over
These BMP could possibly stimulate mesenchymal cells and the HB formation in immobilisation period. Traditionally,
the formation of HB. Piezoelectric osteotomy does not dam- during CCG reconstruction, chin deviation is corrected on the
age osteocytes.23 This viability along with less inflammation table.29 The intraoperative manipulation of the mandible and
helps in early and uneventful healing. Tauro24 stated that bur- maintaining the chin in a new position postoperatively, causes
nishing of the ramal stump and glenoid cavity with a diamond excessive stress and strain in the functional muscle matrix.
fraise without irrigation produces significant osseous thermal This causes the micromotion in CCG, resulting in excessive
damage resulting in the death of osteoblasts and osteoclasts, bone formation. The investigators believe that this may be the
thus reducing the osteogenic potential at the bony interfaces. reason for the excessive growth trigger on the grafted side. In
This strategy may be questionable as a temperature over 47 ◦ C the present study, no intraoperative correction of chin devia-
is required to burn the bone cells. This increased temperature tion was done in patients managed with CCG. This allowed
will increase inflammation and hypoxia of the surrounding undisturbed healing as the muscle matrix was not unduly
tissues resulting in conducive environment for HB forma- stressed. Hence, only a catch-up of growth occured. This
tion. The protocol suggested by the present study is the use technique has been very successful for the authors.9,10
of piezoelectric scalpel and copious irrigation with saline to The use of low dose radiation and non-steroidal anti-
remove all the bone chips that can act as a potential source inflammatory drugs (NSAIDs) in the postoperative period
for HB formation along with growth factors released during have been reported in orthopaedic literature to prevent HB
osteotomy. formation.30 Radiation therapy (RT) and NSAIDs work by
The idea of the interposition of different material was suppressing and preventing the migration of mesenchymal
advocated by Verneuil (1860). This interposition of material cells. The use of radiation in benign lesions is not advised due
will prevent callus formation and consequent local osteogen- to its side effects like xerostomia, impairment of bone healing,
esis and re-ankylosis.7 Autologous fat grafting has been used and the chances of malignancy. This was never considered or
as a means of prevention of fibrosis and heterotopic calci- used in the present study. Prevention of HB formation by
fication in hip prosthesis surgery.25 Autologous fat acts as indomethacin is by its action on inhibition of prostaglandin
a barrier, avoids dead space, and the stem cells present in E2, Cox 1, and 2. Its use as an adjuvant in TMJA patients is
it result in adipogenesis, angiogenesis, and prevents fibro- rare. Indomethacin should be started in immediate postopera-
sis around the joint thereby reducing the formation of HB. tive period as HB formation starts around 16 h postoperatively
Abdominal fat was first used by Wolford and Karras around and reaches its peak at 48 h. Bhatt et al used indomethacin in
alloplastic TMJ TJR.26 In this study, a pedicled BFP or free dose of 75 mg twice daily in 2 multiple recurrent cases and
AF was used. Three patients (2 in the CCG and 1 in the IA observed no re-ankylosis after 2 years. Indomethacin must
group) showed re-ankylosis in the present study, despite the be used with caution in paediatric patients, to avoid renal
fact that it was the same surgical technique and the same sur- complications. This was not used for any case in the present
geon. The authors had a higher re-ankylosis rate, before the study.
use of piezoelectric scalpel and autologous fat grafts.2 The Aggressive physiotherapy is important in preventing re-
action of a pterygomassetric sling is important as this will ankylosis. Physiotherapy should be started in the immediately
reduce the space after osteoarthrectomy. Releasing the sling postoperative period. The department has developed a phys-
will not only nullify its superior pull action to reduce the gap iotherapy regimen.1 Any signs of recurrence should be picked
created, but also allow an easy access to the sigmoid notch for up early in the follow-up period. Most of the recurrence
TJR. In the present study, the sling was always released when happens in the first year after operation. One of the most
TJR was performed. Additionally, there is always release of telling symptoms is the tightness of the joint in the mornings.
some area of the masseter muscle attachment from the zygo- These patients should be encouraged to complete increased
matic arch while performing osteoarthrectomy. It is important physiotherapy and be closely monitored.
to counteract the action of sling, as interposed fat will not stop The strength of the study was in its sample size, that it was
the gap reducing action of the sling. A vacuum drain should single centre study and that the surgery was performed by an
be used as it helps in prevention of haematoma formation experienced surgeon. The ankylosis patients should be fol-
and organisation. This also helps in minimising oedema and lowed up for long period, preferably over 5 years. The present
swelling, allowing for early physiotherapy. study had a shortest follow-up of 12 months and longest of
Re-ankylosis after CCG reconstruction has been reported 80 months. Though most re-ankylosis happens in first year
to be as high as 36.73%.27 The re-ankylosis after CCG is a after surgery, the authors are aware that 12-months is a short
result of micromotion at bone-cartilage interface and extreme time span for comment on re-ankylosis. These patients are
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British Journal of Oral and Maxillofacial Surgery 59 (2021) 820–825

Strategies to reduce re-ankylosis in temporomandibular

Available online 20 February 2021

Introduction 11.97% with different treatment modalities.16 A recent study

eral or bilateral TMJA patients having follow-up records of

The rate of re-ankylosis measures the success of surgical pro-

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