J Oral Maxillofac Surg

66:77-84, 2008

Etiology of Temporomandibular Joint

Ankylosis Secondary to Condylar
Fractures: The Role of Concomitant
Mandibular Fractures
Dongmei He, DDS, MD, PhD,* Edward Ellis III, DDS, MS, and
Yi Zhang, DDS, MD, PhD
Purpose: The purpose of the study was to explore the association between condylar fractures and

temporomandibular joint (TMJ) ankylosis in a sample from 1 hospital in China.

Patients and Methods: All patients treated for post-traumatic TMJ ankylosis in a 5-year period at
Peking University, School of Stomatology, who had sufficient information available were included.
Demographic information and details of their original injury and resultant ankylosis were tabulated and
analyzed by descriptive statistics.
Results: Twenty-five patients with 40 ankylosed joints met the inclusion criteria (15 were bilateral).
The majority of patients were male, and ranged from 5 to 52 years of age with a mean of 23 years.
Twenty-five of 40 cases were the result of a sagittal fracture of the condyle, where the medial pole was
fractured off. Nineteen ankylosed joints (47.5%) showed lateral or superolateral displacement of the
lateral aspect of the ramus/condylar process. Sixteen of 25 patients (64%) had fractures of the mandible
other than condylar fractures located in the anterior mandible that were often untreated or not properly
reduced. Fifty percent of the patients had widening of face or crossbites.
Conclusions: The results of this study indicate that the combination of an intracapsular fracture with
concomitant widening of the mandible leads to the lateral pole of the condyle or the condylar stump to
become displaced laterally or superolaterally in relation to the zygomatic arch, where it fuses. Proper
treatment of the anterior mandibular fracture(s) may help prevent the development of TMJ ankylosis in
such patients.
2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:77-84, 2008
Temporomandibular joint (TMJ) ankylosis is one of
the most disruptive maladies that can afflict the masticatory system. The inability to move the mandible
has significant functional ramifications, such as the
inability to eat a normal diet. Additionally, speech is
affected, making it difficult for some individuals to

communicate and express themselves to others.

When present in the young, growth disturbances of
the face in general and the mandible specifically creates facial asymmetries or severe mandibular deficiencies (when bilateral) that are obvious even when
viewed from a distance. Dental care becomes impossible and the patient often suffers from dental pathology including dental caries and periodontitis. Premature loss of the teeth is common with the inability for
prosthetic replacement.
In addition to functional disturbances, there are
intense psychologic burdens that patients with TMJ
ankylosis must bear from the altered facial appearance, the difficulty of speaking and eating, and the
inability to enjoy the fruits of the culinary arts.
Although the etiology of TMJ ankylosis is categorized
broadly into infections and injuries, the propensity to
the development of TMJ ankylosis is not known. The
most striking finding in the literature concerning this
topic is the perceived frequency of ankylosis in some

*Attending Surgeon, Peking University, School of Stomatology,

Beijing, China.
Professor of Oral and Maxillofacial Surgery, University of Texas
Southwestern Medical Center at Dallas, Dallas, TX.
Professor, Department of Oral and Maxillofacial Surgery, Peking
University, School of Stomatology, Beijing, China.
Address correspondence to Dr Ellis: University of Texas Southwestern Medical Center at Dallas, Division of OMS, University of
Texas, 5323 Harry Hines Boulevard CS3.104, Dallas, TX 753909109; e-mail: Edward.Ellis@UTSouthwestern.edu
2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6601-0013$34.00/0
doi:10.1016/j.joms.2007.08.013

77

78
countries, especially developing countries, and the relative scarcity of this disorder in developed countries.1
Why would individuals in China, Africa, or India have a
higher incidence of TMJ ankylosis than individuals in the
United States or Europe?
Several possibilities exist that might explain this
difference. First and foremost may be that there is not
really a higher incidence in developing countries. It
might be that because of the much greater population
in developing countries and more modern reporting
mechanisms, that the incidence is no different, even
though the number of cases is more voluminous.
If, on the other hand, there is an increased incidence, then one has to ask why. Is there a genetic
predisposition to TMJ ankylosis among individuals in
some countries? Are infectious arthritis and condylar
fractures, the factors linked most commonly to the
development of ankylosis, more common in those
countries? Is it possible that lack of ready access to
health care or poor treatment create the environment
in which TMJ ankylosis can develop more readily?
The purpose of this investigation was to examine a
series of patients treated for TMJ ankylosis to determine if there were any identifiable factors that might
be predisposing factors.

Patients and Methods

The records of all patients who were diagnosed
with traumatic TMJ ankylosis secondary to condylar
fractures at the Peking University, School of Stomatology, from January 2001 to August 2006, were reviewed. The diagnosis of ankylosis was made using
several criteria, including inability to increase the
mandibular opening using physiotherapy before surgery combined with computed tomography (CT) evidence of bony fusion between the condylar process
and the temporal bone, surgical findings of either
fibrous or bony fusion between the condylar process
and the temporal bone, or a combination of fibrous
and bony fusion.
The following information was collected from the
medical record and tabulated: gender, age, cause of
trauma, prior treatment, time between the injury and
presentation to Peking University, and mouth opening (interincisal dimension). The occlusion, facial
symmetry, and facial width were determined by reviewing the photographs that were available on all
patients. Of particular interest was the presence of a
crossbite and widening of the face (unilateral vs bilateral).
All patients had coronal and axial CT scans taken
before surgery to treat the ankylosis and some had 3D
CT reconstructions available. Data obtained from the
CT scans were condyle fracture type (intracapsular vs
extracapsular, horizontal fracture through the head of

TMJ AND FACIAL FRACTURES

FIGURE 1. Computed tomography scan showing bilateral sagittal

fractures of the mandibular condyle with medial pole dislocation,
widening of the intercondylar distance, and superolateral movement of
the lateral pole of the condyle.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

the condyle vs sagittal splitting of the condyle), position of the ramus stump or hemicondyle in relationship to the glenoid fossa, associated mandibular fractures, and width of the mandibular arch.
The type of TMJ ankylosis was recorded from surgery as being fibrous, fibro-osseous, or osseous. The
position of the articular disc was also recorded from
the surgical findings.

Results
Twenty-five patients with TMJ ankylosis had sufficient information available from their medical record
for inclusion in this study. There was a large gender
difference, with 19 males and only 6 females. The
ages ranged from 5 to 52 years with a mean of 22.6
years. The traumatic injury included falls (n 11), car
crashes (n 8), motorcycle crashes (n 4), industrial (n 1), and blast injury (n 1). Thirteen patients (52%) had treatment of their fracture(s) at another facility before presentation for treatment of
ankylosis. Patients presented for treatment of their
ankylosis anywhere from 6 weeks to 7 years after
injury (mean, 20.2 mo). Ten patients had unilateral
and 15 of the patients had bilateral TMJ ankylosis
(total 40 TMJ). All cases of ankylosis were associated with a fracture of the mandibular condyle.
According to the CTs, the most common type of
condyle fracture (n 25/40 joints) was a sagittal
splitting where the medial pole was detached and
displaced (usually anteromedially) but the lateral pole
was still attached to the ramus (Fig 1). The next most
common injury (n 12/40 joints) was a horizontal
fracture of the condylar process at a high level (intra-

79

HE, ELLIS, AND ZHANG

capsular). In 3 joints it was impossible to determine

the type of fracture of the condyle the patient had
sustained because there was a solid mass of bony
fusion between the mandibular ramus and the cranial
base. The stump of the ankylosed mandibular ramus
was positioned within the confines of the articular
fossa in 21 patients (52.5%). Nineteen ankylosed
joints (47.5%) showed lateral or superolateral displacement of the lateral aspect of the ramus/condylar
process. Sixteen of 25 patients (64%) had fractures of
the mandible other than condylar fractures. In each of
these cases, the additional fracture(s) was located in
the anterior region of the mandible. The ability to
open the mouth varied between 0 to 25 mm, with a
mean of 11.3 mm. Two patients had documented
crossbites, and 11 had obvious widening of their face
documented on clinical exam (Fig 2). During surgery,
14 ankylosed joints were categorized as bony, 8 as
fibrous, and 3 as fibro-osseous. The disc was located
anteromedially in every case.

Discussion
The most interesting finding of this study population was the high association of ankylosis with sagittal
fractures of the mandibular condyle. The American
authors experience is strikingly dissimilar to this
studys and warnings in literature that sagittal fractures of the condyle with the medial pole being displaced anteromedially are prone to osteoarthrosis2 or
TMJ ankylosis.3 Such condylar process fractures in
our unit (Dallas) are treated by benign neglect. The
intact lateral pole provides vertical and horizontal
support to the mandible so the only treatment necessary is allowing the patient to function. No case of
TMJ ankylosis resulting from sagittally split condyles
has been seen in patients treated at Parkland Hospital
in Dallas, TX, whereas many cases have occurred in
the Peking University sample. One has to wonder,
therefore, if there is something else that predisposes
such fractures to the development of ankylosis.
The information presented in Table 1 may hold the
key to this query. Sixteen patients with TMJ ankylosis
had concomitant fractures in the anterior mandible
and most of these were associated with superolateral
or lateral displacement of the lateral pole of the sagittally-split condyle. Most of these patients (13/16)
also presented with widening of the mandibular arch
that was reflected in the occlusion or the width of the

FIGURE 2. Frontal (A) and submental (B) views of a patient with

bilateral ankylosis showing widening of the face in the preauricular
and gonial angle regions from malreduction of symphysis fracture.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

80

Table 1. TWENTY-FIVE CASES OF POST-TRAUMATIC TMJ ANKYLOSIS

Age
(yr)

Time Between
Injury and
Presentation
With Ankylosis

Condylar Fx
Location and
Type

Gender

27

MCA

2 mo

15 mm

Fibrous

Bi-head

2
3
4

M
F
M

17
38
49

MVC
MVC
MCA

2 mo
1.5 mo
2 mo

10 mm
18 mm
10 mm

Fibrous
Fibrous
Fibrous

Bi-sagittal
Bi-sagittal
Rt-sagittal

5
6
7

M
M
M

52
20
31

IND
Fall
MVC

2 mo
4 mo
1.5 yr

15 mm

Fibrous
Fibrous
Fibrous

Bi-head
Bi-sagittal
Bi-sagittal

13

MCA

5 mo

15 mm

Fibrous

Bi-sagittal

9
10

M
F

11
19

Fall
MVC

2 mo
6 mo

10 mm

Fibro-osseous
Fibro-osseous

11
12

M
M

25
36

Fall
MVC

3 mo
7 mo

25 mm
20 mm

13
14
15
16
17
18
19
20
21
22

F
M
M
M
M
M
F
M
M
F

18
37
5
8
12
9
8
5
22
28

MVC
MCA
Fall
Fall
Blast
Fall
Fall
Fall
Fall
Fall

2.5 yr
7 yr

23
24
25

M
M
M

6
31
37

Fall
MVC
MVC

N 25

M 19
F6

5-52
Avg
22.6

Etiology

Falls 11
MVC 8
MCA 4
Blast 1
IND 1

Mouth
Opening

Ankylosis
Type

Relationship of
Ramus Stump to
Articular Fossa
Rt-superolateral, Lt
in fossa
Bi lateral dislocation
Bi superolateral
Superolateral

Prior Treatment
of Fx

Mandibular Arch
or Facial
Widening

Symph (linear)

Y Symph fx

Y (cross bite)

Symph (linear)
Symph (linear)
Body (linear)

Y Symph fx
Y Symph fx
Y Body fx

Symph (linear)
Symph (comminuted)
Symph (comminuted)

Y Symph fx
N
Y Symph fx

Y (cross bite)
Y (face wide)
Y (R-angle
prominent)
Y (face wide)
Y (face wide)
Y (Lt-angle
prominent)
Y (face wide)

Associated
Mandibular Fx

Body (linear)

Y Body fx

Bi-sagittal
Rt-sagittal

Bi superolateral
Bi lateral dislocation
Rt-lateral dislocation
Lt in fossa
Rt-superolateral
Lt in fossa
Bi in fossa
Superolateral

None
Body (linear)

Fibro-osseous
Bone

Bi-sagittal
Rt-sagittal

Bi superolateral
Superolateral

Symph (linear)
Symph (linear)

N
Y Body fx and
ORIF Lt
subcondylar
fx w/wire
Y Symph fx
Y Symph fx

1y
2 yr
4 yr
3 yr
3 yr
4 mo
3.5 yr

10 mm
12 mm
5 mm
0
5 mm
12 mm
10 mm
13 mm
5 mm
20 mm

Bone
Bone
Bone
Bone
Bone
Bone
Bone
Bone
Bone
Bone

Y Symph fx
No
No
No
No
Y Symph fx
N
N
N
N

5 mm
0
13 mm

Bone
Bone
Bone

In fossa
Bi in fossa
In fossa
Bi in fossa
In fossa
Bi in fossa
In fossa
In fossa
In fossa
Rt in fossa Lt
superolateral
In fossa
Bi in fossa
Bi superolateral

Symph (linear)
None
None
None
Body (linear)
Symph (linear)
None
None
None
Body (linear)

8 mo
3 yr
6 yr

Rt-sagittal
Bi-sagittal
Lt-head
Bi-head
Lt-head
Bi-head
Lt-Sagittal
Lt-head
Lt-Sagittal
Lt-mass, Rtsagittal
Lt-head
Bi-bone mass
Bi-sagittal

None
Symph (linear)
Indeterminate

Fibrous 8
Fibro-osseous
3
Bony 14

40 sides:
Sagittal 25
Head 12
Bone mass 3

In fossa 21
Superolateral 14
Lateral 5

Associated
mandibular fx
16

N
N
Y ORIF both
cond fx with
wire
Y 13
N 12

1.5 mo-7 yr
Avg 20.2
mo

0-25 mm
Avg
11.3

N
Y (Rt ramus
prominent)

Y (face wide)
Y (Rt ramus
prominent)
No
No
No
No
No
No
No
No
No
Y (left face
wide)
N
N
Y (face wide)

Cases of
increase in
mandibular
arch/facial
width 13

Abbreviations: Avg, average; Bi, Bilateral; fx, fracture; IND, industrial; Lt, left; MCA, motorcycle accident; MVC, motor vehicle (non-motorcycle) collision; N, no; ORIF, open reduction internal
fixation; Rt, right; Symph, symphysis; TMJ, temporomandibular joint; Y, yes.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac Surg 2008.

TMJ AND FACIAL FRACTURES

Patient
No.

HE, ELLIS, AND ZHANG

81
face. Some of these patients had had treatment of the
anterior mandibular fractures immediately after injury
at other facilities (13/16 patients), but it was obvious
by examining the patients when they presented for
treatment of their ankylosis that the surgery to restore
mandibular arch form was inadequate in most (11/13
patients treated for their associated mandibular fracture) (Fig 3).
The locations of the ankylosis in these patients
were largely between the raw edge of the condyle (in
the location where the medial pole used to be) with
the lateral and inferior aspect of the zygomatic arch
(Fig 4). The lateral pole of the condyle was laterally or
superior laterally located, indicating that the treatment of the symphyseal or body fracture(s) was inadequate (Figs 3, 5). For a condyle to be located lateral
to the mandibular fossa, 1 of 2 things had to have
occurred. Unilateral lateral dislocation could occur
even without other mandibular fractures but in such
cases the opposite condyle would have to be positioned medially. This is unlikely and was not seen in
our sample. It could also occur with bilateral condylar
fractures with no other fractures elsewhere in the
mandible, but did not occur in our sample for the 3
bilateral cases of condyle fracture not associated with

FIGURE 3. Posteroanterior skull radiograph (A) and submental 3D CT

scan showing bilateral condylar fractures combined with symphysis
fracture that was treated inadequately, resulting in widening of the
face. Note the gap on the lingual aspect of the symphyseal fracture
(large arrow) resulting in widening of the mandible and inter-ramus
width (small arrows).
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

FIGURE 4. Intraoperative photograph showing fusion of the lateral

pole of the superolaterally-displaced condyle with the zygomatic arch.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

82
another fracture in the mandibular arch. None of
these 3 patients had a combination of lateral displacement on 1 side and medial displacement on the other.
The other method by which lateral or superior dislocation of the lateral pole of the condyle can occur is
for the mandibular arch width to have increased. This
would require another fracture of the mandible and in
keeping with the data from our sample, this is found
commonly and located in the anterior mandible
(16/25 patients; 64%). An associated fracture in the
anterior mandible has also been consistently present
in cases of lateral displacement of mandibular condyles, even without ankylosis.3
The above observation that ankylosis can occur with
a sagittally-split condyle that is laterally or superolaterally
displaced is not new. In 1982, Rowe made the following
observation: In both the adult and the older child there
is an inadequately recognized cause of ankylosis that is
due to an anteroposterior split of the condyle. The
lateral fragment passes upward over the outer rim of the
glenoid fossa and the inner pole, to which the lateral
pterygoid muscle is attached, is displaced antero-medially. The associated displacement of the intra-articular
disc, and the accompanying loss of mobility, frequently
combine to produce an ankylosis.1 Nothing was mentioned about the presence of other fractures of the
mandible, but for the lateral pole of the condyle to be
positioned over the outer rim of the glenoid fossa, it is
likely that other fractures in the anterior portion of the
mandible that allowed widening of the mandible were
present.
The association with TMJ ankylosis after trauma
with other fractures of the mandible is rarely discussed in the literature but there has been some
mention of associated fractures but never has there

FIGURE 5. Intraoperative photograph showing a symphysis fracture

in one of the ankylosis cases that was not reduced properly, resulting
in widening of the face and intercondylar region.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

TMJ AND FACIAL FRACTURES

FIGURE 6. Illustration showing the proposed mechanism of ankylosis

in many of the patients. The articular disc displaces medially along
with the medial pole of the condyle. When the symphysis fracture is
either not reduced or inadequately reduced, the mandible widens
(arrows), allowing the lateral pole of the condyle or ramus stump to
become displaced superolaterally. It then becomes in direct contact
with the bone of the zygomatic arch, where it fuses.
He, Ellis, and Zhang. TMJ and Facial Fractures. J Oral Maxillofac
Surg 2008.

been any association between the other fractures and

the development of ankylosis. Bear and Tankersley4
reported a case of an 11-year-old female who was
involved in a bicycle accident and was treated for a
chin laceration. It was later noted she had a left
mandibular body fracture and a right condylar neck
fracture that progressed to TMJ ankylosis. Similarly, in
a review of lateral condylar displacements even in the
absence of ankylosis, Rattan3 found all cases were
associated with symphyseal fractures.
In describing the characteristics of 81 ankylotic
joints in 56 patients, Norman and Bramley mentioned,
. . . a number were bilateral and associated with a
parasymphyseal fracture and a period of unduly prolonged intermaxillary fixation.5 In the description of
the radiographic findings, it was also mentioned, In
some instances exuberant bone will extend from the
lateral aspect of the mandible to the adjacent zygomatic arch.5 Unfortunately, there was no mention of
whether those with bone bridging laterally between
the ramus and zygomatic arch were those that had
concomitant parasymphyseal fractures.
There are a few other reports of a similar pattern of
osseous fusion in some TMJ ankylosis cases. Swahney6 described 4 forms of TMJ ankylosis and his type
III is one where there is a bony bridge from the ramus
of the mandible to the zygomatic arch. There was no
mention of other associated mandibular fractures in
that report. A similar pattern of osseous fusion was
described by Aggarwal et al.7
Based on the results of our study and the sparse
information in the literature on this topic, one could
put forth the following hypothesis for the develop-

83

HE, ELLIS, AND ZHANG

ment of some cases of traumatically induced TMJ

ankylosis (Fig 6):
1. Fracture of the mandibular condyle (especially
sagittal intracapsular fractures).
2. Associated fracture of the body or symphysis of
the mandible.
3. No or inadequate reduction of associated fracture(s) leading to an increase in the intercondylar distance (or inter-ramus distance at the level
of the stump).
4. Fractured surface of residual ramus or lateral
pole of condyle displaces laterally and possibly
superiorly to the glenoid fossa. As noted in this
study, the articular disc is displaced anteromedially and is no longer interposed between the
fractured fragment of the ramus or lateral pole
of the condyle and the zygomatic arch. Studies
have shown that damage to the articular surface
or removal of the disc are necessary conditions
for the formation of TMJ ankylosis in an animal
model.8-13 Laskin14 considers that the most important feature in a fracture encouraging ankylosis is close contact between the glenoid fossa
and the condylar stump. The conditions found
in our study are therefore ideal for ankylosis.
5. Mandibular hypomobility. This could result from
1 of 3 mechanisms:
a. Patient not seeking treatment and not moving
jaw voluntarily because of pain. This was
noted by Worthington15 who listed hypomobility as one sign of lateral condylar displacement;
b. Inability to move jaw from other conditions
(ie, head injury, mechanical restriction from
lateral displacement of condyle or impingement of coronoid process on zygomatic
arch); or
c. Treatment using a period of maxillomandibular fixation (MMF). This would allow initial
healing between the fresh fractured end of
the ramus or lateral pole of the condyle with
the zygoma.
Although it is impossible to prove this hypothesis
from the data presented, the data is certainly consistent with this mechanism in a large percentage of
cases. If this hypothesis is accurate, it indicates that
treatment should be directed toward properly reducing the fractures in the body/symphysis regions of the
mandible to attain the correct intercondylar distance.
This, by itself, should prevent lateral displacement of
the hemicondyle or ramus stump so that it is unlikely
to move superiorly, over the outer rim of the glenoid
fossa where it can fuse to the zygoma. Obviously, the
other basic tenet of treating intracapsular condylar

fractures must also be used. These patients should be

allowed full unrestricted function of their mandibles
to help prevent organization of the intracapsular hematoma that likely occurs. A review of the literature
on lateral dislocations of the condyle suggested that
such a relationship can lead to fibrosis and ankylosis.3
Although there are many possible reasons why developing countries have an increased number of patients presenting with ankylosis, the most plausible
are an increased incidence of condylar fractures and
unavailability of appropriate care for patients. The
incidence of condylar fractures in China has been
reported to be between 30.7% and 33% of all mandibular fractures,16-18 which is not different from the
world literature.19-23
If an increase incidence in condylar fractures cannot be implicated, then perhaps the unavailability of
proper care may be an important factor in the large
numbers of TMJ ankylosis seen in developing countries. The data in this study may hold a key to why
there are seemingly many more cases of TMJ ankylosis
in developing countries than in more developed ones.
The access to health care is much more limited in
developing countries so mandibular fractures may not
be treated at all. Even the patients in our study who
received treatment for their body or symphysis fracture before presenting with ankylosis were not
treated adequately. Most had under-reduced fractures
of the anterior mandible. This left the intercondylar
distance too great, resulting in laterally or superolaterally displaced condyles, wide faces, or crossbites.
The reason that so many of these patients had underreduced fractures is that they were often treated at
facilities where the surgeon had little experience in
the treatment of facial fractures. It is unclear but
probable that inexperience may have also led to long
periods of MMF. Thus, whether the problem was no
care or inadequate care, the development of TMJ
ankylosis may have been in part, iatrogenic.

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TMJ AND FACIAL FRACTURES

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