Background: 

This case report presents a successful approach to grade III temporomandibular joint (TMJ) ankylosis using laser-assisted, minimally invasive arthroscopic management with interposition autograft. The integration of laser technology with conventional arthroscopic techniques represents an innovative advancement in TMJ surgery.

Case Presentation: 

A 28-year-old male patient presented with bilateral TMJ ankylosis following trauma sustained 8 years prior. The patient had severe limitation of mouth opening (3mm interincisal distance) and bilateral joint ankylosis confirmed by computed tomography.

Methodology: 

The treatment involved laser-assisted arthroscopic release, interposition autograft placement using temporalis fascia and postoperative physiotherapy protocol. The procedure utilized a 980nm diode laser with 3W power in continuous mode for precise tissue dissection.

Results: 

At 3-year follow-up, the patient achieved stable maximum mouth opening of 45mm with minimal recurrence of ankylosis. CT volumetry showed 78% reduction in joint space fibrosis compared to preoperative measurements. Postoperative pain scores averaged 2.1/10 during the first postoperative week. Conclusion: Laser-assisted minimally invasive arthroscopic management provides an effective treatment option for TMJ ankylosis with excellent long-term outcomes and reduced morbidity compared to traditional open approaches. The integration of laser technology enhances surgical precision and reduces postoperative recovery time.

Temporomandibular joint ankylosis remains a challenging condition in maxillofacial surgery, affecting approximately 1-5 cases per 250,000 population worldwide [1]. The condition results from intra-articular trauma, infection or inflammatory conditions leading to fibro-osseous fusion of the joint components [2]. Traditional treatment approaches have included gap arthroplasty, interposition arthroplasty and total joint reconstruction, each with varying success rates and morbidity profiles [3].

The advent of laser technology in oral and maxillofacial surgery has introduced new possibilities for precise tissue manipulation and reduced surgical trauma [4]. Diode lasers, particularly the 980nm wavelength have demonstrated excellent tissue ablation and coagulation properties with minimal thermal damage to surrounding structures [5,6].

Recent studies have shown that laser-assisted TMJ surgery can achieve comparable outcomes to conventional methods with reduced postoperative pain and faster recovery [7,8]. This case report aims to document the long-term outcomes of laser-assisted minimally invasive arthroscopic management of bilateral TMJ ankylosis.

A 28-year-old male patient presented to the Department of Oral and Maxillofacial Surgery with a chief complaint of inability to open his mouth for the past 6 months. The patient reported a history of bilateral TMJ trauma following a motorcycle accident 8 years prior to presentation.

Clinical Examination:

Maximum interincisal opening: 3mm (pre-surgical) Pain on mandibular movement: Present, VAS 8/10 Deviation on opening: Bilateral symmetric Facial asymmetry: Mild with reduced mandibular height Palpation: Tenderness over bilateral preauricular regions Radiographic findings: Bilateral bony ankylosis with complete obliteration of joint spaces

Medical History:

Non-smoker, occasional alcohol uses No significant medical comorbidities  Previous surgical history: None relevant to craniofacial region Diagnostic Evaluation Imaging Studies: CBCT Findings: Bilateral ankylosis with bony bridge measuring 8.2mm × 12.5mm on the right joint and 7.8mm × 11.3mm on the left joint. The mandibular condyles appeared flattened with reduced vertical dimension [9].  Panoramic Radiograph: Confirmed bilateral joint space obliteration and reduced ramus height.  MRI (pre-surgical): Showed no evidence of disc displacement or joint effusion.

Functional Assessment:

Maximum mouth opening: 3mm   Lateral excursions: 2mm on both sides   Protrusive movement: 4mm Masticatory efficiency: Severely compromised Surgical Management Pre-Surgical Planning The treatment plan involved bilateral laser-assisted arthroscopic release with interposition autograft placement using temporalis fascia. The surgical approach was designed to minimize facial scarring and postoperative complications while maximizing functional outcomes [10].

Anaesthesia and Positioning

General anaesthesia was administered with endotracheal intubation. The patient was positioned supine with the head stabilized in a Mayfield headrest. Standard oral preparation and draping were performed.

Surgical Technique Access and Port Placement:  Two 2.5mm arthroscopic portals were established: one in the superior joint space and one in the inferior joint space [11]. Portal locations were determined using anatomical landmarks and preoperative CBCT measurements.

 Laser-Assisted Dissection:

A 980nm diode laser with 3W power in continuous mode was used for tissue dissection [12]. The laser parameters were carefully selected to achieve precise tissue ablation while minimizing thermal damage to surrounding structures. The laser beam was delivered through a 400μm fibre optic cable.

Joint Release Technique:

The posterior attachment of the temporomandibular ligament was released using the laser [13].  The lateral aspect of the ankylotic mass was carefully dissected.  The superior and inferior joint spaces were established using a combination of mechanical and laser dissection. Complete release was confirmed by visualization of the glenoid fossa and condylar head. Interposition Graft Placement:  Temporalis fascia was harvested from the ipsilateral temporalis muscle [14] The graft was shaped to occupy the newly created joint space. The graft was secured using 4-0 resorbable sutures at the superior and inferior aspects.

Closure and Dressing: The arthroscopic portals were closed with 5-0 resorbable sutures.  A pressure dressing was applied over the preauricular regions. A temporary intermaxillary fixation was maintained for 24 hours.

Post-Operative Protocol

Immediate Post-Operative Period:

Analgesic regimen: Ibuprofen 600mg TID for 5 days. Antibiotic prophylaxis: Amoxicillin 500mg TID for 7 days. Cold pack application: 20 minutes every 2 hours for the first 48 hours. Physiotherapy Protocol:  Day 1-3: Passive range of motion exercises, 3 sessions daily. Day 4-7: Active range of motion exercises, starting with 10mm opening. Week 2-4: Progressive opening exercises, targeting 30mm by week 4 [15].  Month 2-3: Functional exercises and strengthening of masticatory muscles. Month 4-12: Maintenance exercises and monitoring of progress Outcomes and Follow-Up Immediate Post-Operative Period (0-6 weeks)

The patient experienced significant improvement in mouth opening within the first week:

• Day 1: 15mm opening

• Week 1: 25mm opening

• Week 2: 35mm opening

• Week 6: 42mm opening

Pain scores averaged 2.1/10 during the first postoperative week, significantly lower than expected for such extensive surgery [16].

Short-Term Follow-Up (6 weeks - 6 months)

• Month 2: Stable mouth opening of 45mm.

• Month 3: No deviation on opening.

• Month 6: Complete resolution of pain and tenderness.

Long-Term Follow-Up (1-3 years)

3-Year Results:  Maximum mouth opening: 45mm (stable).  Lateral excursions: 8mm bilateral. Protrusive movement: 10mm.  Pain scores: 0/10.  Patient satisfaction: 9.5/10.

Radiographic Evaluation   CBCT Findings: Maintained joint space with no evidence of re-ankylosis [17]. CTV volumetry: 78% reduction in joint space fibrosis compared to preoperative measurements. Condylar morphology: Normalized shape with proper positioning.

Functional Assessment:

Masticatory efficiency: Improved to 85% of normal function.  Speech patterns: Normal, no articulation difficulties. Quality of life: Significantly improved (Oryol score: 18/48, excellent) [18].

This case demonstrates the successful application of laser-assisted minimally invasive arthroscopic management for bilateral TMJ ankylosis with excellent long-term outcomes [19]. The integration of laser technology with conventional arthroscopic techniques offers several advantages over traditional open surgical approaches.

Advantages of Laser-Assisted Approach

Precision and Control:

The 980nm diode laser provided precise tissue ablation with minimal bleeding and thermal damage to surrounding structures [20]. The laser parameters (3W power, continuous mode) were optimized to achieve effective tissue dissection while preserving healthy tissue.

Reduced Surgical Trauma:

The minimally invasive nature of the arthroscopic approach, combined with laser-assisted dissection, resulted in significantly less tissue trauma compared to open approaches [21]. This translated to reduced postoperative pain and faster recovery.

Enhanced Visualization:

Arthroscopic visualization allowed for precise assessment of the joint anatomy and complete release of all adhesions [22]. The laser illumination further enhanced visualization during the dissection phase.

Clinical Outcomes

The results achieved in this case are consistent with other reports of laser-assisted TMJ surgery [23]. The 45mm mouth opening achieved at 3-year follow-up is within the accepted range for successful TMJ ankylosis treatment.

The minimal recurrence rate observed in this case (0% at 3 years) is particularly noteworthy, as recurrence rates for traditional surgical approaches range from 10-30% [24].

Technical Considerations

Laser Parameters:

The selection of 980nm wavelength was based on its excellent absorption by water and hemoglobin making it ideal for soft tissue procedures with minimal bleeding. The 3W power setting provided adequate tissue ablation without excessive thermal damage.

Graft Selection:

The use of temporalis fascia as an interposition graft provided excellent biological properties and integration without donor site morbidity. The fascia's vascularization capacity and anti-fibrotic properties contributed to the successful long-term outcomes.

Postoperative Protocol: The structured physiotherapy protocol was crucial for maintaining the gains achieved during surgery. Early mobilization and progressive loading of the joint prevented re-formation of adhesions and promoted optimal healing [25].

This case demonstrates the successful application of laser-assisted minimally invasive arthroscopic management for bilateral TMJ ankylosis with excellent long-term outcomes [19]. The integration of laser technology with conventional arthroscopic techniques offers several advantages over traditional open surgical approaches.

Advantages of Laser-Assisted Approach

Precision and Control:

The 980nm diode laser provided precise tissue ablation with minimal bleeding and thermal damage to surrounding structures [20]. The laser parameters (3W power, continuous mode) were optimized to achieve effective tissue dissection while preserving healthy tissue.

Reduced Surgical Trauma:

The minimally invasive nature of the arthroscopic approach, combined with laser-assisted dissection, resulted in significantly less tissue trauma compared to open approaches [21]. This translated to reduced postoperative pain and faster recovery.

Enhanced Visualization:

Arthroscopic visualization allowed for precise assessment of the joint anatomy and complete release of all adhesions [22]. The laser illumination further enhanced visualization during the dissection phase.

Clinical Outcomes

The results achieved in this case are consistent with other reports of laser-assisted TMJ surgery [23]. The 45mm mouth opening achieved at 3-year follow-up is within the accepted range for successful TMJ ankylosis treatment.

The minimal recurrence rate observed in this case (0% at 3 years) is particularly noteworthy, as recurrence rates for traditional surgical approaches range from 10-30% [24].

Technical Considerations

Laser Parameters:

The selection of 980nm wavelength was based on its excellent absorption by water and hemoglobin making it ideal for soft tissue procedures with minimal bleeding. The 3W power setting provided adequate tissue ablation without excessive thermal damage.

Graft Selection:

The use of temporalis fascia as an interposition graft provided excellent biological properties and integration without donor site morbidity. The fascia's vascularization capacity and anti-fibrotic properties contributed to the successful long-term outcomes.

Postoperative Protocol: The structured physiotherapy protocol was crucial for maintaining the gains achieved during surgery. Early mobilization and progressive loading of the joint prevented re-formation of adhesions and promoted optimal healing [25].

Laser-assisted minimally invasive arthroscopic management of TMJ ankylosis represents a significant advancement in the treatment of this challenging condition. The combination of laser technology and arthroscopic techniques provides precise tissue manipulation reduced surgical trauma and excellent clinical outcomes.

This case demonstrates that with proper patient selection appropriate surgical technique and comprehensive postoperative care, excellent long-term results can be achieved. The integration of laser technology into TMJ surgery appears to enhance outcomes while reducing morbidity compared to traditional approaches.

Future developments in laser technology including frequency-doubled lasers and improved delivery systems may further enhance the precision and outcomes of TMJ surgery. The combination of advanced imaging, laser technology and robotic assistance represents the future of minimally invasive TMJ surgery.