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Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 27  |  Issue : 6  |  Page : 661-663
Brisement force in fibrous ankylosis: A technique revisited


Department of Oral and Maxillofacial Surgery, HKES, S. N. Dental College and Research, Gulbarga, Karnataka, India

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Date of Submission09-May-2016
Date of Decision25-Jun-2016
Date of Acceptance14-Nov-2016
Date of Web Publication7-Feb-2017
 

   Abstract 

Fibrous ankylosis is a common complication of trauma to the temporomandibular joint (TMJ) in children. Proper treatment and regular follow-up is necessary for its successful management. This report highlights a case of posttraumatic fibrous ankylosis successfully managed with brisement force-gradual tractional forces applied to the TMJ under local anesthesia without any associated complications. Mouth opening increased significantly from 15 to 35 mm. The patient was advised to perform rigorous physiotherapy at home, to maintain interincisal opening of 35 mm. The case was followed up for 6 months with no decrease in mouth opening.

Keywords: Brisement force, fibrous ankylosis, physiotherapy, trauma

How to cite this article:
Joshi UM, Patil SG, Shah K, Allurkar S. Brisement force in fibrous ankylosis: A technique revisited. Indian J Dent Res 2016;27:661-3

How to cite this URL:
Joshi UM, Patil SG, Shah K, Allurkar S. Brisement force in fibrous ankylosis: A technique revisited. Indian J Dent Res [serial online] 2016 [cited 2017 Apr 30];27:661-3. Available from: http://www.ijdr.in/text.asp?2016/27/6/661/199591
The term “Ankylosis” is a Greek word, meaning “stiff joint.” It may be defined as the immobility or consolidation of a joint due to disease, injury, or surgical procedure. Mandibular hypomobility occurs from direct injury to or due to disorders affecting the supporting structures of the temporomandibular joint (TMJ). TMJ ankylosis is an intra-articular process characterized by fibrous, fibro-osseous, or osseous obliteration of the joint space.[1] Trauma to the TMJ is the most common cause of ankylosis which can occur either due to forceps delivery or a fall on the chin. Other than trauma, odontogenic infections, otitis media, mastoiditis,[2] previous TMJ surgery, orthognathic surgery [3] can predispose to ankylosis. True ankylosis of the TMJ is defined as any condition that produces fibrous or bony adhesions between the articular surfaces of the joint.[4] TMJ ankylosis protocols suggest early surgical intervention, elaborate resection, early mobilization, and aggressive physiotherapy for at least 6 months postoperatively.[5] One of the nonsurgical methods proposed for treatment of fibrous ankylosis is the application of brisement force, principal aim of which is to restore motion inhibited by the fibrous pathology in the TMJ complex and to rehabilitate function lost due to disuse. Presented here is a case report of a posttraumatic fibrous ankylosis managed with brisement force applied to the TMJ.


   Case Report Top


A 15-year-old female patient reported to the Department of Oral and Maxillofacial Surgery at our institution with the chief complaint of reduced mouth opening associated with pain for 8 months. The patient had a history of trauma 9 years back in which she sustained injuries to the chin. There is a positive history of right ear bleed with no history of loss of consciousness, convulsions, and vomiting. The patient was taken to the hospital and suturing was done to close the laceration on the chin after which medications to relieve pain were prescribed. The patient was also advised orthopantomogram, but since the patient was relieved of pain, the radiographic investigation was not done. Over the years, reduction in mouth opening associated with pain was observed by the patient. On the day she reported to the department, the interincisal opening was 15 mm [Figure 1]. Extraorally, facial asymmetry was noted with the lower third of the face on the right side appearing more rounded and the left side appearing flattened with a deviation of the chin to the right. There was decreased condylar movement on the right side. Intraorally, the dental midlines did not coincide with the mandibular midline away from the maxillary midline by 4 mm toward the right.
Figure 1: Reduced mouth opening of 15 mm

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The patient was advised orthopantomogram which revealed irregularity of the articulating surfaces of the right TMJ. Features of the right condylar fracture which was displaced anteromedially were noted. The joint space on the right appeared narrowed with a slight increase in its radiopacity. Antegonial notch was prominent on the right side [Figure 2]. A diagnosis of right TMJ fibrous ankylosis was formulated.
Figure 2: Orthopantomogram

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The patient was advised the application of brisement force under local anesthesia, using a Fergusson mouth gag wrapped with thick pad of gauze to avoid dental trauma. This procedure enabled us to achieve an interincisal opening of 35 mm [Figure 3]. The patient was advised to perform physiotherapy, which included mouth opening exercises using Heister's mouth gag and a block of wooden ice-cream sticks held together with the help of rubber bands to maintain the interincisal opening of 35 mm [Figure 4]. The case was followed up for 6 months with no decrease in mouth opening.
Figure 3: Application of brisement force and achieving a mouth opening of 35 mm

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Figure 4: Use of wooden ice-cream sticks held together with the help of rubber bands to maintain the interincisal opening of 35 mm

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The correction of the deviation of chin on opening of mouth was achieved using an elastic traction with e-chain placed on an arch bar [Figure 5]. The postoperative mouth opening achieved was satisfactory functionally [Figure 6].
Figure 5: Correction of the deviation of chin upon opening of mouth was achieved using an elastic traction with e-chain placed on an arch bar

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Figure 6: Postoperative mouth opening

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   Discussion Top


The hypomobility or immobility of TMJ may be due to various reasons, ankylosis being one of them. Trauma and infections account for the majority of the etiology in TMJ ankylosis. In children below the age of 10 years, fall on the chin causes indirect trauma to the condyles.[6] Fractures of the condyle in children are more prone toward developing into ankylosis due to the typical anatomy of the pediatric condyle, which has a broad neck and highly vascularized head that has rich osteogenic potential compared to an adult condyle. It is hypothesized that the extravasation of the blood into the joint called as hemarthrosis, along with the disruption of the fibrocartilage integrity, permits the ingrowth of fibrous connective tissue into the joint which subsequently results in ossification, leading to the fusion of mandibular condyle to the articular surface of the temporal bone. The most common types of fractures reported include the intracapsular crush fractures of the condylar head and high condylar fracture through the neck above the sigmoid notch.[7] The TMJ disc plays an important role in preventing ankylosis by acting as a barrier between the articulating surfaces. Damaged or displaced discs might predispose the disease.[8]

Ankylosis in children is a serious and disabling condition with impairment of speech, difficulty in mastication, poor oral hygiene, rampant caries, disturbances of facial and mandibular growth, and compromise of airway present a unique challenge to maxillofacial surgeon in terms of patient's physical and psychological management.[5] Osseous ankylosis presents characteristic radiographic features which facilitate the diagnosis. Fibrous ankylosis is a clinical diagnosis rather than radiographic as fibrous tissue cannot be deciphered on the radiographs.

A variety of techniques for the treatment of TMJ ankylosis have been described, but no single method has produced uniformly successful results.[9] However, the treatment should be initiated as soon as the condition is recognized with the main objective of re-establishing the joint function.[10] In the management of fibrous ankylosis, the forced opening of the jaw with the application of the brisement force is the oldest method. In this procedure, the jaw is forced open by means of a mouth gag and mobilized as much as possible by forceful manipulation. After jaw has been mobilized, the patient may be further benefitted by exercise with the rubber block inserted between the teeth on the affected side.[11] The use of ice cream sticks held together with a rubber band or Heister's mouth gag can also be used to maintain the interincisal opening consistent.


   Conclusion Top


Through this case report, it can be proposed that the application of brisement force to the TMJ in fibrous ankylosis is a feasible method with minimal to nil associated complications and high success rates. Patient compliance is as important as a programmed and coordinated treatment plan to yield optimal results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

 
   References Top

1.
American Association of Oral and Maxillofacial Surgeons: Parameters and Pathways. Clinical practice guidelines for oral and maxillofacial surgery (AAOMS Para Path 01), Version 3.0. J Oral Maxillofac Surg 2001;59 (8) Suppl 1:1-160.  Back to cited text no. 1
    
2.
Ghali GE. Temporomandibular disorders. In: Milaro M, editor. Peterson's Principles of Oral and Maxillofacial Surgery. 2nd ed., Vol. 2. People's medical publishing house-USA: B.C. Decker Inc.; 2004. p. 933-1033.  Back to cited text no. 2
    
3.
Ward Booth P. Ankylosis of the TMJ. Maxillofacial Surgery. 2nd ed., Vol. 2. Churchill Livingstone: Elsevier; 2007. p. 1524-6.  Back to cited text no. 3
    
4.
Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189-93.  Back to cited text no. 4
    
5.
Shashikiran ND, Reddy SV, Patil R, Yavagal C. Management of temporo-mandibular joint ankylosis in growing children. J Indian Soc Pedod Prev Dent 2005;23:35-7.  Back to cited text no. 5
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6.
Ogunlewe MO, James O, Ladeinde AL, Adeyemo WL. Pattern of paediatric maxillofacial fractures in Lagos, Nigeria. Int J Paediatr Dent 2006;16:358-62.  Back to cited text no. 6
    
7.
Kalia V, Singh AP. Greenstick fracture of the mandible: A case report. J Indian Soc Pedod Prev Dent 2008;26:32-5.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Toyama M, Kurita K, Koga K, Ogi N. Ankylosis of the temporomandibular joint developing shortly after multiple facial fractures. Int J Oral Maxillofac Surg 2003;32:360-2.  Back to cited text no. 8
    
9.
Erdem E, Alkan A. The use of acrylic marbles for interposition arthroplasty in the treatment of temporomandibular joint ankylosis: Follow-up of 47 cases. Int J Oral Maxillofac Surg 2001;30:32-6.  Back to cited text no. 9
    
10.
Das UM, Keerthi R, Ashwin DP, VenkataSubramanian R, Reddy D, Shiggaon N. Ankylosis of temporomandibular joint in children. J Indian Soc Pedod Prev Dent 2009;27:116-20.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Thoma KH. Oral Surgery. 5th ed., Vol. 2. Saint Louis, U.S.: The C. V. Mosby Company; 1969. p. 649-700.  Back to cited text no. 11
    

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Correspondence Address:
Udupikrishna M Joshi
Department of Oral and Maxillofacial Surgery, HKES, S. N. Dental College and Research, Gulbarga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.199591

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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