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tmj-ankylosis

tmj-ankylosis

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ANKYLOSIS OF TMJ& ITS SURGICAL MANAGEMENT

Dr. saritha devi III M.D.S

CONTENTS 
INTRODUCTION  CLASSIFICATION  ETIOPATHOLOGY  CLINICAL FEATURES  DIAGNOSIS  RADIOGRAPHIC FEATURES  KABANS PROTOCOL FOR MANAGEMENT OF

ANKYLOSIS  VARIOUS APPROACHES TO TMJ  SURGICAL PROCEDURES

INTRODUCTION 
Inability to open the mouth beyond 5mm of inter-incisal opening due to fusion of

head of the condyle of the mandible with the articulating surface of the glenoid fossa is termed as ´ Ankylosis of the TMJ  When the structures outside the joint are involved, it is termed "false ankylosisµ. 

in contrast when the disease involves the TMJ itself, it is called "true ankylosisµ. When the joint space is obliterated by dense mass of sclerotic bone, then it is termed as bony ankylosis. When the joint space is obliterated by fibrous adhesions, then it is termed fibrous ankylosis. 



CLASSIFICATIONS 
CLASSIFICATION OF ANKYLOSIS:    

1. False ankylosis or true ankylosis. 2. Extra - articular or intra - articular. 3. Fibrous or bony. 4. Unilateral or bilateral

hampers the jaw movements.  2. infection adjoining the muscles of mastication involving submasseteric .pterygomandibular.ETIOPATHOLOGY OF FALSE ANKYLOSIS  MUSCULAR TRISMUS ‡ It can be established because of pericoronitis.temporal or submandibular spaces. When there is hematoma formation & progressive ossification after injury and especially of the masseter muscle. MYOSITIS OSSIFICANS ‡ . infra .  3. MUSCULAR FIBROSIS ‡ Muscular fibrosis from long standing dysfunction like a arthritis and myositis etc. inability to open the mouth develops.

and hemorrhage in medulla oblongata are also represented by hypomobility of the jaw. 4. TRISMUS HYSTERICUS ‡ It is disease of psychogenic origin. NEUROGENIC CAUSES ‡ Neurogenic causes like epilepsy. brain tumour. TETANY When there is hypocalcaemia.  7. ‡ .  5. the spasms in the muscles are produced hampering the opening of the mouth. TETANUS ‡ Acute infectious disease caused by Clostridium tetani is represented by an early symptom of lock-jaw because of persistent tonic spasm of the muscles.  6.

 9. 8. FRACTURE OF THE ZYGOMATIC ARCH ‡ Fracture of the zygomatic arch with inward buckling will cause mechanical obstruction to coronoid process and hence restricting the movements of the mandible.MECHANICAL BLOCKADE ‡ Mechanical blockade on account of osteoma or elongation of the coronoid process of the mandible reduces movement of condyle under the zygomatic arch. .

ETIOPATLOGY OF TRUE ANKYLOSIS  Birth trauma producing so-called congenital ankylosis and occurs in cases of difficult delivery.  Haemarthrosis is another cause of ankylosis. It is generally. . particularly forceps delivery. due to: fracture of the base of skull extending through the mandibular fossa - may also be caused by an intracapsular injury.

 Suppurative arthritis. may cause great limitation of motion or complete ankylosis  Osteomyelitis affecting the mandibular condyle without involving the joint itself frequently results in limitation of motion & muscular trismus . may be due to infection of the ear or mastoiditis leading to ankylosis  Rheumatoid arthritis.

neglected oral hygiene & carious teeth. Early joint involvement . functional loss severe. Healed chin laceration in case of trauma Reduced interincisal mouth opening . it is present only in the early stages of the disease. But. Pain is not an outstanding symptom. Later joint involvement after the age of 15 years: Facial deformity marginal or nil. Those patients in whom the ankylosis develops after full growth completion have no facial deformity. 1. ‡ ‡ ‡ ‡ ‡ ‡ ‡ . 2.less than 15 years: Severe facial deformity and loss of function. (b) Time of onset of ankylosis. difficulty or inability to masticate food.‡ ‡ ‡ CLINICAL FEATURES Clinical manifestations vary according to: (a) Severity of ankylosis.

BILATERAL ANKYLOSIS  Bird face deformity + micro gnathic mandible+receeding chin  Class II malocclusion  crowding + protrusive upper anterior teeth + anterior open bite  Prominent antegonial notch on both the sides .

Prominent Ante-gonial notch on the affected side . UNILATERAL ANKYLOSIS Facial asymmetry with affected side appearing normal & the opposite side appearing flat.1. This is because the normal side continues to grow & pushes the mandible to the affected side giving appearance of fullness on the ankylosed side. 3. Chin is deviated to the ankylosed side. 2.

History of infection or trauma (birth trauma + falls + previous infection of the ear)  2. Radiological findings .DIAGNOSIS BASED ON  . Findings at clinical examination (reduced interincisal opening + diminished/no TMJ movements + scar on the chin due to trauma)  3.

‡ PA view will show the mediolateral extent of the bony mass ² also reveal any mandibular asymmetry. Lateral oblique ² will demonstrate the antero-posterior extent of the bony mass and the elongation of the coronoid process  CT Scan/3D CT Scan ² gives relationship to the middle cranial fossa and internal carotid artery (carotid canal) medially to the ankylotic mass ² usually not seen in conventional radiographs 3D CT SCAN showing Bony ankylosis ‡ .FOR PROPER EVALUATION SEVERAL RADIOGRAPHS ARE USEFUL ‡ Orthopantomograph: OPG will show both the joints for comparision ² and in unilateral cases ²will also reveal ante-gonial notching.

. CONE BEAM 3D CT SCAN ²The cone beam CT provides multiple images of the maxillofacial area with less radiation than traditional CT beam.

RADIOGRAPHIC CHANGES  decreased ramus height on the affected side  Joint space is completely or partially obliterated with dense sclerotic bone  prominent antegonial notch on the affected side.  Sometimes a transverse or oblique dark line crossing the mass of dense bone is seen showing fibrous ankylosis .  elongation of coronoid process.

.

if CCG used.  Lining of joint with temporalis fascia or the native disc.KABAN·S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS-2009  Aggressive excision of fibrous and/or bony mass  Coronoidectomy on affected side  Coronoidectomy on opposite side if maximum mouth opening is less than 35 mm . early mobilization with minimal intermaxillary fixation (not more than 10 days)  Aggressive physiotherapy . mobilize day of surgery. if it can be salvaged  Reconstruction of Ramus condyle unit with either DO or CCG and rigid fixation  Early mobilization of jaw: if DO used to reconstruct RCU.

Submandibular incision 3.SURGICAL APPROACHES TO TMJ      1. Endaural incision . Preauricular incision with modifications 2. Post ramal 5. Post auricular 4.

PRE-AURICULAR INCISION & ITS MODIFICATIONS .

BRAMLEY INCISION Alkayat .Bramley incision is a modification of the preauricular incision where the upper part of the incision is extended in a question mark fashion over the temporal area to gain better access .ALKAYAT .

Incision B parallels or is within the resulting skin tension lines.  the incision should be 1. Incision B makes a less Conspicuous scar in most patients. Incision A parallels the inferior border of the mandible.5 to 2 cm inferior to the anticipated location of the inferior border.Submandibular approach  Two locations of submandibular incisions. .

POST-AURICULAR  The incision in the postauricular approach begins near the superior aspect of the external pinna and is extended to the tip of the mastoid process. The superior portion may be extended obliquely into the hairline for additional exposure.  Excellent posterolateral exposure is afforded with this technique .

POST-RAMAL APPROACH .

ENDAURAL INCISION  The incision begins well within the external auditory meatus at the superior mental wall. with the knife in continuous contact with the tympanic plate. to make a semicircular incision to the inferior point of the meatus. .  The incision is now continued inferiorly.

 PRE-SURGICAL OPERATIVE CONSIDERATIONS Intubating the patient for General anaesthesia may be a problem as the patient has minimal to no mouth opening.    . Techniques such as blind nasal. Blood loss may be significant at the time of surgery especially in children & there should be plans for blood transfusion. Only when it is not possible to intubate with these procedures should a tracheostomy be considered. fibre-optic or retrograde intubation may need to be employed.

In the second stage surgery an orthognathic surgery can be planned to restore facial esthetics. ‡ ‡ ‡ .TIMING OF SURGERY  Surgery for Ankylosis can be done in 2 stages: In the first stage surgery. only release of ankylosis with costochondral graft in young patients is done to bring about jaw mobility and growth. Some surgeons prefer to use a single stage procedure where release of ankylosis and esthetic correction are done in a single stage in adults or after cessation of growth spurts in children.

Types of Surgical procedures  1. . Condylectomy  2. Gap arthroplasty  3. Interpositional Arthroplasty.

there is not much deformity of condylar head. Indications :  Fibrous ankylosis cases. where the joint space is obliterated with deposition of fibrous bands.CONDYLECTOMY  Condylectomy is complete surgical removal of mandibular condyle  First performed by Humprey in 1856 to treat TMJ ankylosis . . but.

 Disadvantage  Procedure .

GAP ARTHROPLASTY  First done by abbe  Indications : In extensive bony ankylosis  Technique  Disadvantages  Complications .

Requirements for interpositional material  Biologically and chemically inert  Noncarcinogenic  Adaptable to molding at operative site  Strength and rigidity.INTERPOSITIONAL ARTHROPLASTY  To prevent re-ankylosis after gap arthroplasty insertion of an interpositional material is advocated.  Numerous materials have been used as interpositional material for temporomandibular joint to prevent re-ankylosis.  If the disc of the joint is found the disc is mobilized & positioned to cover the glenoid fossa. but the temporal fascia is the most widely used interpositional material. .

Materials used for Interpositional gap arthroplasty  AUTOGENOUS MATERIALS Cartilagenous  Costochondral  Metatarsal  Sternoclavicular  Auricular cartilage Muscles  Temporal muscle  Fascia lata  Dermis .

.Advantages :  Biological acceptability  Remodelling by appositional growth specially in children Disadvantages:  Donor site morbidity  Potential overgrowth of chostochondral graft.

ALLOPLASTIC MATERIALS Metallic  Tantalum foil/plate  Stainless steel  Titanium  Gold Non metallic  Silastic  Teflon  Acrylic nylon  Ceramic implants .

Advantages :  No donor site morbidity  Immediate return of function Disadvantages :  Foreign body reaction  Erosion of metal condylar prosthesis in glenoid fossa  Loosening of screws and loss of stability .

 The graft materials that are used for the total joint reconstruction are Autogenous grafts  Costochondral graft  Metatarsal head graft  Sternoclavicular joint  Calvarial grafts Alloplastic materials  Kent ² vitek  Christensen type I  Christensen type II .TOTAL JOINT RECONSTRUCTION  Recurrent fibrosis or bony ankylosis not responsive to other modalities of treatment .

 For the patient who has reankylosis. mandibular function is typically delayed. Although the autogenous grafting techniques develop form. . early mandibular mobility often leads to graft/host interface failure. complete bony TMJ ankylosis has been managed with gap arthroplasty with autogenous tissue graft or alloplastic reconstruction. placing autogenous tissue such as bone into an area where reactive or heterotopic bone is forming is not logical. Because graft mobility during healing compromises its incorporation with the host environment or its blood supply.HOW WE HAVE TO SELECT THE RECONSTRUCTIVE MATERIAL DEPENDING ON THE CONDITION ?  Traditionally.

Quinn .References  Temporomandibular joint disorders and occlusion : Jaffery okeson  Temporomandibular disorders : Fonseca  Contemporary oral and maxillofacial surgery : Peterson  Oral and maxillofacial surgery : Daniel M. Laskin  Colour atlas of temporomandibular joint surgery : Peter D.

. J. Leopard : Surgery of the non-ankylosed temporomandibular joint : British journal of oral and maxillofacial surgery 1987: 25: 138-148. Troulis : A Protocol for Management Of Temporomandibular Joint Ankylosis in Children : J Oral Maxillofac Surg 67:19661978. Ankylosis of the temporomandibular joint. Mercuri : Total Joint ReconstructiondAutologous or Alloplastic : Oral Maxillofacial Surg Clin N Am 18 (2006) 399²410. 27: 67² 79. J R Coll Surg Edinb 1982.References  P. 2009  Louis G.  Leonard B.  Rowe NL. Carl Bouchard and Maria J. Kaban.

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