Background
Materials and methods
Search strategy
Eligibility criteria
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Population (P): Patients diagnosed with TMJ ankylosis.
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Intervention (I): Physiotherapy interventions.
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Comparison (C): No specific comparison is stated in the question.
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Outcome (O): Efficacy in the management of TMJ ankylosis.
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Study Design (S): This study considered Randomized Controlled Trials and other empirical research study designs.
Data selection and extraction
Author | Study Design | Sample Size | Mean age | Study Objectives | Aetiology | Clinical Presentation | Physiotherapy techniques used | Findings |
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Ahmad et al. (2015)/ [17] | A Prospective Comparative Study | 28 | Unspecified | To assess modified T-plate interpositional arthroplasty | Trauma, infection, and re-ankylosis | TMJ ankylosis causes facial deformities and reduced mouth opening. Reduced mouth opening causes malnutrition | One day after surgery, active physiotherapy began. Wooden spoons measured mouth openings and physiotherapy efficacy | The modified T-plate interpositional arthroplasty approach is practical in managing TMJ ankylosis |
Bayat et al. (2009)/ [18] | Retrospective study | 34 | 21.5 | To evaluate gap and interpositional arthroplasty with temporalis muscle flap for TMJ ankylosis | Trauma and osteochondroma | Bony ankylosis | Physiotherapy is an essential part of the treatment At least six months of physiotherapy is recommended. Therabite device | Gap and interpositional arthroplasty using the temporalis muscle flap effectively manage TMJ ankylosis |
Braimah et al. (2018)/ [19] | Retrospective study | 36 | 13.8 ± 6.6 | To evaluate the TMJ ankylosis management approach | Trauma due to a fall | Bony and fibrous ankylosis | Effective therapy requires intensive postoperative physiotherapy for six months. Preventing re-ankylosis requires jaw physiotherapy | Active physiotherapy is essential for managing TMJ ankylosis |
Dowgierd et al. (2022)/ [20] | Single-center prospective cohort study | 33 | 14.24 ± 3.23 | To outline TMJ ankylosis treatment | Inflammatory, trauma, and congenital or iatrogenic | Early intervention approach for temporomandibular ankylosis in children and adolescents using 3D virtual surgical planning and customized biomaterials | Before temporomandibular prosthesis insertion, intensive physiotherapy improves mandible function | Gap arthroplasty and thorough therapy before temporomandibular prosthesis outweighed costochondral autografts |
Elgazzar et al. (2010)/ [35] | Clinical retrospective study | 101 | 19.43 | To explore the experience of managing TMJ ankylosis and compare the outcomes of different protocols | Trauma, previous TMJ surgery, osteoarthritis, hyperplasia, and infection | Bony, fibrous, and ankylosis | - Physiotherapy was a vital part of the treatment - Patients were encouraged to continue mouth-opening exercises at home. massage, and deep heat therapy | Timely TMJ ankylosis release, bone grafting during ramus height reconstruction, and vigorous physiotherapy are efficient management approaches for TMJ ankylosis |
Erol et al. (2006)/ [36] | Clinical study | 59 | 18 ± 6.4 | To explore the experience of managing TMJ ankylosis | Otitis media, Rheumatoid Arthritis, landslide, traffic accident, birth forceps trauma, and falls | Bony and fibrous ankylosis | Physiotherapy helps avoid postoperative adhesions and re-ankylosis.—Start post-op exercises and physiotherapy immediately | - Falls were the most common cause of ankylosis.—Early postoperative exercises and physiotherapy are essential |
Fariña et al. (2018)/ [37] | Clinical study | 15 | 11.4 | To establish a treatment approach for TMJ ankylosis emphasizing functional and morphological efficacy | Unspecified | TMJ ankylosis leads to functional and morphological deficits and stunted craniofacial development | - Physiotherapy is fundamental for the stability of treatment results.—It consists of specific exercises performed multiple times a day | The proposed algorithm is functionally and morphologically efficient in managing TMJ ankylosis |
Güven O (2000)/ [38] | A clinical and retrospective study | 42 | Unspecified | To explore the historical background of TMJ ankylosis management | Trauma and Infection | Unilateral ankylosis: mandible hypoplasia, chin deviation on the affected side Bilateral ankylosis: severe retrognathia, mandibular alveolar protrusion, open-bite deformity, bird-face look, hypertrophic and thick coronoid process, night snoring, OSA | - Physiotherapy was used as part of the treatment protocol.—Physiotherapy was reported to be painful Mouth opening and closing exercises using wooden gags and an inter-insical acrylic gag with a jack screw | The spherical acrylic spacer offers a shorter operating time and is economical |
Hegab A. F (2015)/ [39] | A Prospective Clinical Study | 14 | 18.5 median age (12—38) | To investigate the efficacy of ankylosis management using pathogenesis | Trauma and falls | - Patients with TMJ ankylosis - Preoperative assessments included patient history, clinical and radiologic examinations | - Wooden tongue blades used - Immediate, continuous aggressive physiotherapy for six months.—Physiotherapy helps prevent adhesions and redevelop muscle function | The treatment protocol is efficient in managing TMJ ankylosis and preventing re-ankylosis |
Jain et al. (2008)/ [21] | Retrospective study | 44 | 13.814 | To explore TMJ ankylosis management protocols | Falls from heights can cause chin trauma and otitis media | Bony and fibrous ankylosis | Ferguson's mouth gag and wooden Tongue blades Physiotherapy after surgery is essential for long-term maintenance.—Postoperative intense jaw physiotherapy for six months | Timely TMJ ankylosis management is critical. In addition, aggressive physiotherapy is essential for long-term postoperative outcomes |
Jakhar et al. (2013)/ [40] | Clinical study | 90 | 14 | To investigate the significance of condyle and disc retention in ankylosis management | Trauma | - Severely limited mouth opening with mandibular deviation - No palpable condylar movements or joint pain | - Lack of postoperative physiotherapy led to recurrence in 3 patients.—Intensive physiotherapy program started on the third day postoperatively | The condyle and disc preservation effectively manage TMJ ankylosis with various advantages |
Kaban et al. (1990)/ [22] | Retrospective study | 14 | 18.33 ± 12.56 | To investigate the efficacy of a TMJ ankylosis management protocol | Trauma, ankylosing spondylitis, and osteochondroma | Fibro-osseous ankylosis, fibrous ankylosis, and bony ankylosis | Aggressive physiotherapy is necessary to eliminate adhesions and avoid soft-tissue constriction. The physiotherapy regimen includes heat, massage, ultrasonography, gum chewing, manual stretching, and the Bell Dynamic Jaw Exerciser | The treatment protocol is effective in managing TMJ ankylosis |
Khalifa G. A (2018)/ [41] | Prospective observational clinical study | 26 | 16.27 ± 1.48 | To assess mouth-opening changes after gap arthroplasty | Unilateral condylar fracture, Bilateral condylar fracture, and Chin trauma | Type I, II, III, and IV | Mouth gags, mouth prop, and chewing gum | Maximum interincisal opening assessment is critical for the timely detection of re-ankylosis |
Kohli et al. (2017)/ [23] | A Prospective Comparative Study | 22 | 24.5 | To compare condylar reconstruction approaches regarding function and morphology | Unspecified | - Similar mean mouth opening in both groups | Jaw exercises with mouth gag | Sternoclavicular grafts treat TMJ ankylosis better than transport distraction osteogenesis |
Lo et al. (2008)/ [42] | Clinical study | 19 | 29.12 | To develop and clinically test a TMJ exerciser | Trauma, mandibular, Orthognathic surgery for cleft deformity, and facial fracture | - TMJ hypomobility and trismus - Patients with various causes of TMJ dysfunction | - The new exerciser is a satisfactory device for physiotherapy of TMJ hypomobility and trismus Power screw technique | The maximal incisor opening increased significantly after using the device |
Longobardi et al. (2009)/ [24] | Observational Cohort Study | 18 | 31.3 | To assess the efficacy of a three-phase treatment protocol for managing TMJ ankylosis | Previous condylar fractures, Caustic burn, Postsurgical scar, Pyogenic infection, Pseudocamptodactylia, and Trauma with loss of substance | - Limitations in oral opening due to ankylosis | Bite block - Physiotherapy is a phase of the treatment protocol - Physiotherapy is challenging to undertake immediately after surgery | The 3-phase treatment protocol is efficient for managing TMJ ankylosis |
Nitzan et al. (2012)/ [25] | Retrospective Case Series | 13 | 20 | To explore an alternative treatment approach to TMJ ankylosis using computed tomography | Trauma | Condylar fracture | - Treatment includes intensive supervised physiotherapy | The condyle and disc head displacement are efficiently searched using computed tomography Only ankylotic material is accurately removed, retaining the condyle-disc apparatus |
Nouman and Hassan (2017)/ [43] | Experimental study | 15 | Unspecified | To evaluate the efficacy of physiotherapy following TMJ ankylosis surgery | Unspecified | - TMJ ankylosis interferes with chewing, speech, and oral hygiene - It can cause gross facial deformities if not treated | Facial exercises, electrical stimulation, and using an ice cream stick - Mouth opening exercises and electrical stimulation were used - Facial exercises and home exercise programs implemented | Physiotherapy and mouth-opening exercises are essential in managing TMJ ankylosis |
Park et al. (2019)/ [44] | Clinical study | 9 | 35.4 | To assess the effectiveness of interocclusal splint for physiotherapy in managing TMJ ankylosis | Trauma and infection | Fibrous, bony ankylosis, Chronic osteomyelitis, pseudo ankylosis, and stylohyoid ligament calcification | Interocclusal splint - Physiotherapy helps prevent adhesion and re-ankylosis | Ankylosed mass resection and physiotherapy are essential in managing TMJ ankylosis |
Rahman et al. (2020)/ [45] | Clinical and Radiological Study | 15 | 12.6 | To evaluate the suitability of dermal fat for reducing pain during active physiotherapy | Fall from height and infection of the ear | Osseous or fibro-osseous ankylosis | Early, intensive postoperative physiotherapy is crucial | The dermis fat graft could be a superior choice in managing TMJ ankylosis |
Sahoo et al. (2012)/ [46] | Clinical study | 64 | 14.3 | To compare the outcomes of alternative approaches for managing TMJ ankylosis | Trauma, infection, and systemic illness | Limitations in mouth opening, dentofacial deformities, malocclusion, poor oral hygiene, dental caries, aesthetic impairment, malnutrition, and OSA | Ice cream blades - Non-compliance to postsurgical physiotherapy led to re-ankylosis - Active physiotherapy was carried out postoperatively for six months | Interpositional arthroplasty with temporalis myofascial flap is effective for mild mandibular deformities |
Sami et al. (2023)/ [26] | Prospective study | 12 | 11.2 | To compare the outcomes of using temporalis fascia as an interpositional graft | Fall from height and ear infections | Unspecified | Early, intensive postoperative physiotherapy is crucial Physiotherapy prevents and treats TMJ hypomobility and ankyloses | Cutaneous fat grafts and temporal fascia are effective when treating TMJ ankylosis |
Shetty et al. (2019)/ [27] | Retrospective study | 98 | 20 | To evaluate the outcomes of a two-phase physiotherapy approach after consecutive ankylotic mass resection | Unspecified | Problems with mastication, talking, and mouth opening (re-ankylosis) are common | - A novel physiotherapy procedure involving two stages was demonstrated - The success of the physiotherapy treatment relies heavily on patient acceptance | The longevity and rigidity of interpositional graft insignificantly influence the outcomes of TMJ ankylosis management |
Shivakotee et al. (2020)/ [28] | Case series | 18 | 17.66 | To measure the effectiveness of treatments for TMJ ankylosis | Trauma and Congenital | - Mastication, digestion, speech, and hygiene can all be affected by TMJ ankylosis - Common among young children | - Physiotherapy is emphasized for all patients | Interpositional arthroplasty with vascularized temporalis fascia flap can avoid re-ankylosis |
Singh et al. (2014)/ [29] | Retrospective study | 15 | 12.2 | To assess lateral arthroplasty for TMJ ankylosis | Trauma | - Trauma was the etiological factor in all cases | Mouth prop, mouth gag, and spoon spatulas - Postoperative physiotherapy began on day one The therapy comprised active and passive exercises | Type III ankylosis patients benefit from the medially displaced condyle and disc |
Singh et al. (2012)/ [30] | Prospective study | 10 | 17.7 | To assess the suitability of sternoclavicular graft as an interposition graft in managing TMJ ankylosis | Trauma and infection | - 10 patients with TMJ ankylosis, aged 12–35 years - Complete osseous ankylosis, mean duration 6.4 years | Mouth prop, mouth gag, and spoon spatulas - The physiotherapy treatment comprised active hinge-opening and excursive movements | Sternoclavicular Graft, Buccal Fat Pad Lining interposition, and active physiotherapy are essential for managing TMJ ankylosis |
Tauro and Manay (2020)/ [31] | Observational cohort study | 21 | 19 | To propose modifications to the surgical approaches in managing and minimizing re-ankylosis | Unspecified | 21 patients with TMJ ankylosis | - Aggressive intermittent intraoperative jaw physiotherapy - Rigorous postoperative jaw physiotherapy | The proposed approach effectively minimizes re-ankylosis |
Lin et al. (2019)/ [32] | Retrospective study | 32 | Unspecified | To explore the outcomes of retaining the medially displaced residual condyle in managing TMJ ankylosis | Accidental impact, violence, and accidental fall | - Limited ability to open mouth, difficulties with eating and speech | - Physiotherapy involves active and passive mandibular movement and maximal mouth-opening exercises | The displaced condyle should be preserved in managing TMJ ankylosis |
Yadav et al. (2021)/ [33] | Retrospective study | 114 | 15.75 ± 9.76 | To investigate a method for reducing re-ankylosis after TMJ ankylosis surgery | Trauma and infection | - 114 patients (n = 152 joints) evaluated retrospectively - Interpositional arthroplasty, costochondral graft, and complete joint replacement were used | Tapered acrylic trismus screw - Aggressive physiotherapy is vital to prevent re-ankylosis | The risk of re-ankylosis can be minimized by following the proposed treatment protocol |
Younis et al. (2020)/ [47] | Prospective Clinical Comparative Study | 30 | 6.5 | To compare cutaneous fat graft and temporalis myofascial flap as interposition grafts for TMJ ankylosis | Trauma and otitis media | - TMJ ankylosis causes difficulty in chewing, speech, and oral hygiene | Wooden spatulas - Physiotherapy techniques were used in the study | Dermis fat grafts may be better than temporalis myofascial flaps for treating TMJ ankylosis |
Zhang & He (2006)/ [48] | Retrospective study | 18 | 28 | To assess condylar fracture-related TMJ ankylosis and postoperative outcomes | Trauma | - Type I ankylosis develops in the 4th to 5th-month post-trauma with 183 ± 55 mm mean interincisal opening | Physiotherapy | Disc repositioning is effective for TMJ ankylosis management - Close follow-up for 18 months after condylar fractures - Surgical intervention for fibrous ankylosis after two months |
Methodological quality assessment
Data analysis
Results
Study selection
Methodological quality assessment
Author | Objectives clearly stated | Well-defined research population | At least 50% of those eligible participate | Participants from similar groups | Justification of sample size, power, variance, and effect estimates | Interest exposures before outcomes | A realistic timeframe to correlate exposure and consequence | Overall rating |
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Ahmad et al. (2015) [17] | Y | Y | Y | Y | N | Y | Y | G |
Bayat et al. (2009) [18] | Y | Y | Y | Y | N | Y | Y | G |
Braimah et al. (2018) [19] | Y | Y | Y | Y | N | Y | Y | G |
Dowgierd et al. (2022) [20] | Y | Y | Y | Y | N | Y | Y | G |
Jain et al. (2008) [21] | Y | Y | Y | Y | N | Y | Y | G |
Kaban et al. (1990) [22] | Y | Y | Y | Y | N | Y | Y | G |
Kohli et al. (2017) [23] | Y | Y | Y | Y | N | Y | Y | G |
Longobardi et al. (2009) [24] | Y | Y | Y | Y | N | Y | Y | G |
Nitzan et al. (2012) [25] | Y | Y | Y | Y | N | Y | Y | G |
Sami et al. (2023) [26] | Y | Y | Y | Y | N | Y | Y | G |
Shetty et al. (2019) [27] | Y | Y | Y | Y | N | Y | Y | G |
Shivakotee et al. (2019) [28] | Y | Y | Y | Y | N | Y | Y | G |
Singh et al. (2014) [29] | Y | Y | Y | Y | N | Y | Y | G |
Singh et al. (2012) [30] | Y | Y | Y | Y | N | Y | Y | G |
Tauro and Manay (2020) [31] | Y | Y | Y | Y | N | Y | Y | G |
Lin et al. (2019) [32] | Y | Y | Y | Y | N | Y | Y | G |
Yadav et al. (2021) [33] | Y | Y | Y | Y | N | Y | Y | G |
Study characteristics
Prevalence and clinical presentation of TMJ ankylosis
Physiotherapy interventions approaches for TMJ ankylosis
Efficacy of physiotherapy interventions in TMJ ankylosis management
Adverse effects and safety of physiotherapy interventions
Discussion
Limitations of the evidence included in the review
Implications for clinical practice
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1. Treatment Protocol Optimization: Clinicians should consider incorporating physiotherapy techniques, such as wooden spoons, Therabite devices, personalized mouth gags, and specific exercises, to improve postoperative outcomes and minimize the chances of re-ankylosis.
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2. Patient Compliance and Education: Healthcare professionals should educate patients about the benefits of physiotherapy and the potential consequences of non-compliance, including re-ankylosis and other postoperative complications.
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3. Risk and Complication Management: Healthcare practitioners should be vigilant in monitoring patients after surgery, mainly to prevent complications such as hematomas, infections, facial nerve palsy, and re-ankylosis. Adherence to predefined protocols for postoperative care is crucial in minimizing the incidence of adverse events. Regular follow-up appointments are essential to evaluate the long-term outcomes and address emerging complications.
Implications for policy
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1. Standardized Treatment Guidelines: Policymakers should consider developing standardized treatment guidelines for TMJ ankylosis. These guidelines should include recommendations for incorporating physiotherapy techniques as an integral part of the treatment process.
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2. Access to Physiotherapy Services: Policymakers should evaluate the availability and accessibility of physiotherapy services for patients with TMJ ankylosis. Ensuring that these services are readily available to patients, regardless of geographical location or financial barriers, would support optimal postoperative outcomes and reduce the likelihood of complications or re-ankylosis.
Implications for future research
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1. Randomized Controlled Trials: Future research should focus on conducting well-designed randomized controlled trials with larger sample sizes. These trials would provide a higher level of evidence on the effectiveness and safety of physiotherapy techniques for TMJ ankylosis.
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2. Long-term Follow-up Studies: Longitudinal studies with extended follow-up periods are needed to evaluate the sustained outcomes of various treatment protocols for TMJ ankylosis. These studies would provide insights into the long-term functional improvements, rates of recurrence, and potential complications associated with different treatment approaches.
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3. Comparative Effectiveness Research: Comparative effectiveness research comparing various physiotherapy techniques and treatment approaches would help determine the most effective interventions for TMJ ankylosis. This research would assist clinicians in making informed decisions regarding selecting treatment protocols for individual patients.