Int. J. Oral Maxillofac. Surg.

2009; 38: 1256–1262

doi:10.1016/j.ijom.2009.07.016, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Intraoral approach for E. C. Ko1,2,3,*, M. Y. Chen2, M. Hsu1,

E. Huang1, S. Lai1
1
Oral and Maxillofacial Surgery Department,

arthroplasty for correction of Kaohsiung Medical University Hospital,

Taiwan; 2Oral and Maxillofacial Surgery
Department, Taichung China Medical
University, Taichung, Taiwan; 3Division of Oral

TMJ ankylosis and Maxillofacial Surgery, the University of

Tokyo, Tokyo, Japan

E. C. Ko, M. Y. Chen, M. Hsu, E. Huang, S. Lai: Intraoral approach for arthroplasty

for correction of TMJ ankylosis. Int. J. Oral Maxillofac. Surg. 2009; 38: 1256–1262.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. This study evaluates the authors’ technique using the intraoral approach for the
management of temporomandibular joint (TMJ) ankylosis. The technique was used on
16 TMJs in 14 patients with a mean age of 28.5 years; their average postoperative
mouth-opening was 33.7 mm. All the patients had Sawhney’s type IV TMJ ankylosis
except a child with type I. One patient had recurrent ankylosis and was managed using
the same intraoral approach again. Average follow-up was 56 months. The protocol
consists of interpositional arthroplasty via an intraoral approach and aggressive mouth-
opening exercises. An intraoral incision is made over the buccal shelf and the soft tissue
of the mandibular ramus reflected. Osteotomy is carried out at the coronoid process and
adequate osteotomy is accomplished at the level of the condylar neck. Adequate gap
osteotomy at the ankylosed condyle is performed and followed by placement of the
Keywords: TMJ ankylosis; arthroplasty; in-
interpositional material, such as rib cartilage, masseter, buccal fat pad and traoral approach.
costochondral graft. The wound is then closed meticulously. The advantages of this
intraoral approach are excellent cosmetic appearance with no facial scar, lower risk of Accepted for publication 7 July 2009
injury to the facial nerve or auriculotemporal nerve and no salivary fistula formation. Available online 3 September 2009

Treatment of temporomandibular joint
(TMJ) ankylosis is challenging. TMJ
ankylosis in children and adolescents
can result in mandibular underdevelop-
ment, facial deformity and adverse phy-
siological and psychological effects.
Surgical intervention and forceful post-
operative mouth-opening exercises are
required to achieve adequate oral function.
Surgical approaches to the ankylosed TMJ
include preauricular2,4, endaural14, post-
auricular1 and submandibular13 incisions;
each has advantages and disadvantages
(Table 1). Reported complications of these
techniques are temporary or permanent
facial nerve paralysis, sialocele, hemor-
rhage, poor access to the ankylosed area,
and scarring. Facial nerve injury can occur
during incision and reflection of the soft
tissue. As Obwegeser11 said ‘‘the first goal
for any surgeon, whatever he or she does,
must be to avoid unnecessary harm (nil
nocere).
The intraoral approach is the alterna-
tive. Lai was the first to use the intraoral
approach for TMJ arthroplasty for anky-
losis in 1989. The authors did not find any
literature describing the intraoral approach
for management of TMJ ankylosis prior to
1989, though several articles mention
intraoral approaches to the condyle. The
purpose of this article is to evaluate the
intraoral approach for management of
TMJ ankylosis.
Patients and methods
Since 1989, the authors have carried out
intraoral arthroplasties on 16 TMJs in 14
patients. The technique was performed by
four different surgeons at two medical
*
Division of Oral and Maxillofacial Sur-
gery, The University of Tokyo, 7-3-1 Hongo,
Bunkyo-ku, Tokyo, 113-8655, Japan.

0901-5027/1201256 + 07 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Table 1. Different approaches to the TMJ.
Approach Author
Preauricular Blair4
Al-Kayat2,
Bamley2
Postauricular Alexander1
Endaural Rogetti14
Perimeatal Eggleston6
(preauricular
+ postauricular)
Submandibular Risdon13
Bicoronal Pogrel12
centers in Taiwan. There were 7 male and
7 female patients, aged 10–61 years (mean
age 28.5 years). The age at onset of anky-
losis ranged from 0 to 59, with a mean age
of 18.2 years. 3 of the 14 patients had
undergone surgery at other hospitals with
unsatisfactory results before referral. The
average postoperative mouth-opening
dimension was 33.7 mm (Table 2).
All the patients had Sawhney’s type IV
TMJ ankylosis except for the child (patient
No. 5) with type I fibrous ankylosis. The
criterion for patient selection was TMJ
ankylosis, regardless of type and age. One
patient had recurrent ankylosis and was
managed via the same intraoral approach
again. Follow-up ranged from 3 months to
10 years, with an average of 56 months. One
patient had bilateral TMJ ankylosis, another
underwent a second arthroplasty 10 months
after the first due to inadequate postopera-
tive mouth-opening physiotherapy.
Surgical technique
The procedure is carried out under general
anesthesia via the nasotracheal route. An
Intraoral approach for arthroplasty for correction of TMJ ankylosis
Year Advantages
1914 Exposure of anterior portion
of zygomatic arch
1979
1975 Avoid possible facial nerve
injury, salivary fistula and
formation of a sialocele
Minimal swelling
Less discomfort
Shorter operation hours
Esthetics
1954 Excellent access to the
lateral and posterior
aspect of TMJ
Good exposure of the
anterior aspect of TMJ
Esthetics
1978 Access to glenoid fossa
No damage to frontal
branch of facial nerve
Avoid stenosis or infection
of the cartilage
1934 Better access and visualization
(in combination with preauricular)
1991 Simultaneous access to both
TMJs using one incision
Superior approach
Good access
Enables harvesting of the
temporalis m and fascia
Minimal chance of facial injury
incision of 4 cm is made at the buccal shelf
(Fig. 1). The location corresponds to the
area of the anterior border of the mandib-
ular ramus and the external oblique ridge.
The posterior incision extending upwards
should not be higher than 5 mm above the
occlusal plane to avoid injury to the buccal
nerve as a result of severence or traction.
The soft tissue from the inner and outer
surface of the mandibular ramus and por-
tions of the mandibular angle is reflected
(Fig. 2). It is best to reflect the coronoid
process as high as possible with the cor-
onoid retractor to allow the greatest expo-
sure and access. The malleable retractor is
introduced onto the inner surface of the
coronoid process and the channel retractor
placed at the posterior border for surgical
field and soft tissue protection (Fig. 3).
Prior to osteotomy of the coronoid pro-
cess, the wires may be passed into the
holes drilled superior and inferior to the
planned osteotomy. This is better for
reduction of the osteotomized coronoid
process or if coronoidectomy is required;
the wire aids dissection and removal of the
coronoid process. The coronoid process is
1257
Possible complications/Disadvantages
Facial nerve paralysis
Paresthesia of auriculotemporal nerve
Salivary fistula, sialocele
Scarring
Frontal nerve injury
Stenosis of external auditory canal
Infection
Paresthesia (temporary or permanent)
of the external pinna
Deformity of the auricle
Perichondrtis with esthetic compromise
(loss of tragal projection)
Poor access to the entire zygomatic arch
Difficult to extend the incision
Possible injury to the marginal mandibular
and cervical branches of facial nerve
Greater area for reflection
Time-consuming for pre-op preps
Compromised esthetic as hair shaving
required
Temporary weakness of frontal nerve
cut off with a reciprocating saw and dis-
placed into the inner surface for better
access (Fig. 4a), so the ankylosed area is
visible. Reflection of the scar tissue from
both inner and outer surfaces of the anky-
losed area is accomplished as much as
possible with the periosteal elevator. A
malleable retractor is then placed at the
inner aspect of the ramus to protect the
internal maxillary artery that lies imme-
diately deep to the condylar neck and the
channel retractor moved upwards for bet-
ter access to the ankylosed area. A gap is
created with a round bur and No. 703 bur
at the planned condylar neck area to sepa-
rate the mandible and the ankylosed area
(Fig. 4b). Generally, the osteotomy is
placed at the level of the sigmoid notch
or a little higher. A chisel could be used if
prefered. The size and shape of the gap is
different in various arthroplasties using
different interpositional materials.
A coronoid retractor is better for retract-
ing and exposing the coronoid process
than a bone clamp and is mandatory for
this intraoral approach. A coronoid retrac-
tor can control the area of exposure and the
1258 E.C. Ko et al.

Table 2. Patient characteristics.

3 mos. 6 mos.
Age at pre-op post-op post-op Nos of Duration of
intraoral MMO MMO MMO 1 yr post-op Interpositional prior follow-ups
Pt No. surgery Onset Sex Side (mm) (mm) (mm) MMO (mm) materials surgery Causes (months)
1 26 5 F Lt 0 40 43 43 Rib cartilage 0 Infection 89
2 31 26 M Bil. 1 21 5 — Rib cartilage 1 Trauma 5
3 17 6 F Lt 0 29 33 23 (10 yrs Rib cartilage 0 Trauma 120
post-op)
4 24 18 M Lt 11 35 31 30 Rib cartilage 0 Trauma 46
5 10 0 M Rt 29 34 37 39 Rib cartilage 0 Congenital 120
6 24 5 F Lt 0 34 36 39 Rib cartilage 2 Trauma 72
7 28 8 M Rt 16 47 45 — Rib cartilage 1 Trauma 96
8 49 46 M Lt 8 36 17 —** Masseter 0 Trauma –
8* 50 46 M Lt 3 37 34 25 Rib cartilage 1 Trauma 29
9 25 17 F Lt 11 37 41 not Rib cartilage 0 Trauma 84
available
10 18 8 F Rt 0 32 32 35 Rib cartilage 1 Trauma 64
11 21 19 M Rt 15 31 not not Rib cartilage 0 Trauma 3
available available
12 25 20 F Lt 20 37 40 not Rib cartilage 0 Trauma 6
available
13 19 18 F Lt 20 41 39 40 Buccal fat pad 0 Trauma 24
14 61 59 M Lt 10 36 36 36 Buccal fat pad 0 Trauma 24
*
Patient No. 8 underwent surgery twice on the same TMJ.
**
The interval between the two arthroplasty surgeries for patient No. 8 was less than 1 year; hence, there is no. 1 yr post-op dimension for the
first surgery.

direction of access and reflect the upper lip
of the patient providing better access and
visualization.
It is best to make the distal end of the
mandibular ramus convex and make the
proximal end concave to lodge the inter-
Fig. 1. Intraoral incision.
positional materials such as the costochon-
dral graft or rib cartilage. This preparation
of the recipient site (Fig. 5) allows the rib
cartilage or costochondral graft to be
secured to the artificial fossa for ideal
simulated geometric anatomy. This avoids
displacement or dislodgement especially
during the aggressive postoperative
mouth-opening exercises. For the place-
ment of the interpositional material, there
is no major difference between the
intraoral and the extraoral approach, but
it requires surgeons with skill and a better
sense of orientation. The importance of
preparation cannot be overemphasized;
the proximal end should be shaped as
concave as the fossa to allow secure lodg-
ment and better stability. Wires were used
to fix the costochondral graft. It is not
necessary to place wires or anything else
to fix the rib cartilage graft. The simulated
anatomy of the fossa can secure the
motion of the pseudojoint. The surgical
field is irrigated copiously with large
amounts of normal saline and the wound
closed meticulously. In general, no drain is
placed, but an extraoral drain was placed
for patient No. 5 via the additional Risdon
approach for the placement of the costo-
chondral graft.

Postoperative mouth-opening exercises

and follow-up
Mouth-opening exercises began 3 days
postoperatively, and continued for 6
months. Patients are requested to undergo
exercise 6 times a day for the initial 2
months, to maintain the maximal dimension
of mouth opening for 10 min each time.
Fig. 2. (a) Outer surface of the mandible (hatched area) is larger and more extensive when using From the postoperative third month, exer-
costochondral graft as the interpositional material. (b) Inner surface of the mandible (hatched cise is requested 3 times a day. A mouth gag
area). is used for the first 2 or 3 days and then a

Fig. 3. Reflection and retraction with the
coronoid (ramus) retractor to expose the cor-
onoid process as high as possible. A malleable
retractor was placed at the inner aspect of the
coronoid process and the channel retractor
was placed at the posterior border of the ramus
for exposure of the surgical filed.
custom-made resin block attached to the
wooden spatula16 or to the mouth gap is
used to facilitate mouth opening in stability.
Patients No. 13 and No. 14 received acu-
puncture and both felt more comfortable
undergoing the mouth-opening exercise
after acupuncture. There are too few cases
to compare the effects of acupuncture. Reg-
ular follow-up was carried out every week
for 2 months, every month for the following
Fig. 4. Osteotomy. (a) Cutting off the coronoid process with a reciprocating saw for access to
the ankylosed area. The coronoid process was then displaced into the inner aspect to gain direct
access to the ankylosed area. (b) Osteotomy was carried out using a round bur and a No. 703
fissure bur. The gap was made at the area where the original condylar neck should be.
Fig. 5. Placement of interpositional materials (a) rib cartilage (b) superolateral view of the rib cartilage, as the convex surface to accommodate the
simulated fossa (c) costochondral graft.
Intraoral approach for arthroplasty for correction of TMJ ankylosis
10 months, every 6 months for 3 years and
yearly until 6 years postoperatively. The
mouth opening distance was recorded and
imaging examination including panoramic
radiograph or computed tomography was
included in the follow-ups.
Results
In 14 patients the average postoperative
mouth opening dimension was 33.7 mm
excluding the postoperative dimension
following the first surgery for the reanky-
losis case (Table 2). The increased dimen-
sion of mouth opening ranged from 10 to
43 mm, with a mean increased dimension
of 24.0 mm, excluding the value of the
postoperative dimension before the sec-
ond surgery for the reankylosis case
(patient No. 8). If the dimension at the
time of reankylosis was also included in
the calculation, the increased dimension
was averaged as 23.0 mm. The average
postoperative dimension of mouth open-
ing is 32.6 mm including the postoperative
dimension following the first surgery for
the reankylosis case.
Discussion
Intraoral arthroplasty can avoid the com-
plications of the extraoral approach for
TMJ arthroplasty. The advantages of
1259
intraoral arthroplasty are no facial scar, less
possibility of injuring the facial nerve and
the auriculotemporal nerves, no sialocele,
less hemorrhage, simultaneous coronoi-
dectomy or coronoidotomy with better
direct access to the ankylosed condyle
via the same incision, an easier solution
for cases in which there is an extensive
ankylosed area. The disadvantages include
the limited surgical field, the requirement
for the surgeon to have a good sense of
orientation, the limitations regarding the
selection of interpositional material and
the skill required from the surgical assis-
tants. The inner surface of the ramus above
the mandibular foramen is reflected for
placement of the retractor to protect the
internal maxillary artery during the osteot-
omy. This gives the intraoral approach an
advantage over the extraoral approach
because there is less risk of hemorrhage.
Several articles mention the intraoral
approach to the condyle (Table 3). Moose10
used the medial approach to perform obli-
que condylotomy for mandibular prognath-
ism (Fig. 7a). Moose noted the difficulty
encountered in cases with the maxilla in
proximity to the internal surface of ramus.
The higher risk of inferior nerve injury
should be considered. The medial approach
is not possible for access to the ankylosed
TMJ because adequate preoperative mouth
opening is the precondition for the medial
approach. Winstanley20 used the intraoral
lateral approach oblique condylotomy for
the management of mandibular prognath-
ism. Shevel19 first used open condylotomy
using Moose’s approach on patients with
anterior disc displacement. Dislocation of
the proximal fragment led Shevel to aban-
don Moose’s medial approach in favor of a
lateral intraoral approach with the mandible
wired in occlusion before the jaw is sec-
tioned. Sear18 used the lateral approach for
condylectomy applied to condylar hyper-
plasia (Fig. 7b). The coronoid process
hinders the surgical procedure of the con-
dyle and limits surgical access. Habel8
proposed a transcoronoidal approach for
fracture of the condylar neck for the direct
1260 E.C. Ko et al.

mended that 2 holes, placed 5 mm away

Fig. 6. Patient No.1 with extensive left TMJ ankylosis, including the whole coronoid process.
(a) Preoperative panorex. (b) Panorex of postoperative day 2. Interpositional TMJ arthroplasty
was performed above the mandibular foramen. (c) Panorex of postoperative 1 year and 7 months,
with bony remodeling.
visualization and manipulation of the prox-
imal and distal fragments (Fig. 7c). Prior to
completing temporary osteotomy of the
coronoid process, a mini-screw of appro-
priate length and breadth is driven into the
anterior margin of the coronoid process.
This ensures accurate repositioning of the
osteotomized coronoid process on comple-
tion of the fracture reduction. Vertical
osteotomy of the temporary coronoid pro-
cess might be difficult to perform because
of the indirect and limited access. The
authors also use the transcoronoidal
approach, but without the vertical osteot-
omy of the ramus. Güven7 performed TMJ
arthroplasty for ankylosis with the addi-
tional intraoral approach on 6 patients aged
over 12 years.
The transcoronoid approach allows bet-
ter access to the ankylosed area. The cor-
onoid can be left off or re-fixed at the end
of surgery. It is difficult to find and fix the
coronoid process because of the superior
pull of the temporalis muscles. It is recom-
from the anterior border of the ramus, are
drilled in advance superior and inferior to
the planned coronoid osteotomy area. A
26 gauge stainless-steel wire should be
passed through the superior hole before
the coronoid osteotomy. The fractured
coronoid process can then be easily found
and returned to its preoperative place at
the end of surgery. Leaving the coronoid
process fractured, may make it easier for
the patient to undergo mouth-opening
exercises because there is less pull from
the temporalis muscles. In that situation,
neither drilling nor wiring is necessary.
According to Kaban’s9 protocol, ipsilat-
eral coronoidectomy is mandatory so the
intraosseous wire is useful for removing
the coronoid process by pulling it out with
wire.
Rotskoff15 introduced the idea that
high-level resection allows better mandib-
ular opening and lateral movements. The
closer the osteotomy to the original loca-
tion of the TMJ, the better the function of
the mandible. High-level resection has a
higher recurrence of ankylosis. He
deemed low-level resection easier to per-
form with a lower recurrence rate but only
allowing hinge movement in the pseudo-
joints. The authors do not agree with the
latter. Newly formed pseudojoint should
be considered free to allow translation
movements regardless of the level at
which the osteotomy was placed. Good
lateral movement of the affected side
should be determined by the postoperative
physical mouth-opening exercises.
Kaban9 describes aggressive resection
of the ankylotic segment, but this protocol

Table 3. Comparison of the intraoral approaches to condyle.

Limitations for management
Author Year No. Originally designed for Approach Possible complications of TMJ ankylosis
Moose10 1964 25 Condylotomy for Medial Inferior nerve paresthesia Impossible with medial approach
mandibular prognathism
Dislocation of the proximal
segment
Winstanley20 1968 30 Mandibular prognathism Lateral As Moose’s Indirect access
Inferior nerve paresthesia
(author did not mentioned)
Sears18 1972 2 Condylectomy for Lateral Inferior nerve paresthesia Indirect access for the existence
condylar hyperplasia (author did not mentioned) of coronoid process

Shevel19 1991 46 Ant. disc displacement Medial, later Inferior nerve paresthesia Indirect access for the existence
abandoned of coronoid process
for lateral
Author did not mentioned
Habel8 1990 1 Condylar neck fracture Lateral and Inferior alveolar nerve Difficult to perform vertical
transcoronoid paresthesia (author not osteotomy
mentioned)
Lai 2006 14 TMJ ankylosis Lateral and Temporary or permanent Temporal muscle and fascia:
transcoronoid nerve injury to inferior absolute contraindications
alveolar nerve
Bleeding from internal maxillary artery could not be ruled out for possible incomplete reflection and protection.

Fig. 7. Review of intraoral techniques (processed from the original articles). (a) Moose’s medial
approach for subcondylar osteotomy. (b) Sear’s condylectomy for unilateral condylar hyper-
plasia. (c) Habel’s transcoronoidal approach to fractures of the condylar neck.
may result in perforation of the middle
cranial fossa. The surgical risk is consid-
erable and the advantage gained marginal,
since complete elimination of the ankylo-
tic bone creates an extensive area of heal-
ing bone where scar tissue will form.
Salins17 proposed ‘subankylotic osteot-
omy’ below the ankylosed area, instead
of aggressive resection. His technique
offers a departure from the conventional
philosophy of management of cranioman-
dibular ankylosis. Creation of a pseudoar-
throsis leaving the ankylotic mass
undisturbed appears to eliminate a major
cause of reankylosis, simplifies the tech-
nique, reduces the surgical risk and
improves the results. Salins’ technique
has special merit in the management of
recurrent ankylosis and in cases with
extensive ankylotic mass. Since the base
of the ankylotic bone is usually at a lower
level on the medial aspect, Salins noted it
was essential to place the osteotomy at
best 5 mm inferior to the base of the
ankylotic mass as visualized on the lateral
aspect.
The authors thought that the best place
for gap osteotomy might be at the anky-
losed area where the smallest horizontal
dimension is found and where it is easier
to cut off. The corresponding area at the
either side of the gap is also the smallest,
which would be of great help in reducing
the incidence of TMJ recurrence.
Rib cartilage is the main interpositional
material used by the authors for this
intraoral technique. The cartilage should
be made convex at the superior aspect and
Intraoral approach for arthroplasty for correction of TMJ ankylosis
concave at the lower aspect (Fig. 5). A
costochondral graft was used only for the
pediatric patient (No. 5). Risdon incision
was used for placement of the costochon-
dral graft and wire fixation. The authors
have also used the buccal fat pad as the
interpositional material because of its
proximity to TMJ and for its ease of
harvesting. No additional mucosal inci-
sion was needed for harvesting the buccal
fat pad but it requires more delicate skill to
place the buccal fat into the bony gap and
to suture it onto the neighboring soft tis-
sue. Dimitroulis’5 dermis-fat is also indi-
cated for this intraoral technique. It is
impossible to harvest temporalis muscle
or fascia3 via the intraoral approach.
Pediatric patients are more difficult to
manage using the intraoral technique
alone because of the smaller volume of
tissue and poorer access. For patient No. 5,
a costochondral graft was placed and fixed
with stainless-steel wire using the Risdon
approach13; it might have been practical,
but difficult, to complete the procedure
using trocar without additional extraoral
approaches.
The patient with bilateral TMJ ankylo-
sis had undergone prior surgery elsewhere
for TMJ ankylosis but following recur-
rence had been referred to the authors.
The ankylosis was classified as type IV
because the ankylosed area extends over
the sigmoid notch and coronoid process.
The authors performed osteotomy
between the ankylosed area and the man-
dibular foramen and placed rib cartilage
graft for interpositioning. Intraoperative
1261
mouth opening following osteotomy was
satisfactory at 40 mm. The patient was
afraid of pain and discomfort during the
mouth-opening exercises, which were
unsuccessful. Recurrence was related to
the inadequacy of the mouth-opening
exercise.
Some patients (Nos. 1, 10, 14) can
achieve greater amounts of opening than
during surgery under general anesthesia.
Patient No.1 (Fig. 6) had 26 mm of mouth
opening intraoperatively but reached
40 mm 3 months after surgery with her
aggressive mouth-opening exercises. She
has maintained mouth opening of 40 mm 7
years and 5 months later. It is essential to
instruct the patients to continue the mouth-
opening exercise to prevent TMJ reanky-
losis.
Acknowledgements. We are very grateful
to Prof. Tsuyoshi Takato, Dr Kazuto
Hoshi, Dr Toru Ogasawara, Dr Ina Peiy-
ing Chang, Dr Joseph Chuchiang Kao,
Dr Chiaming Chang, Dr Kazuyo Igawa,
Dr Yuko Fujihara, Dr Daichi Chikazu
and Dr Yushun Kao for their help. This
paper was presented as an oral free paper
at the 17th International congress of Oral
and Maxillofacial Surgery in Vienna in
the summer of 2005 and received a
Modus award as one of the free papers
presented in October 2004 at the 6th
Asian Congress in Tokyo. Line illustra-
tions in Figs. 1–5 were originally
depicted by Dr Steven Lai. All illustra-
tions were processed by Mr. Peter Chen-
ghao Ko, www.kozy.com.tw.
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Address:
Steven Lai
Oral and Maxillofacial Surgery Department
Kaohsiung Medical University Hospital
100 Shih Chuan 1st Road
Kaohsiung City
Taiwan
Tel.: +886 7 312 1101–9x7024, 7005.
E-mail: stevla@kmu.edu.tw