TMJ ANKYLOSIS

Prof.Dr.REENA RACHEL JOHN

Assoc.Dean Research
VMSDC Salem
TMJ ANATOMY
 CAUSES OF TMJ ANKYLOSIS

➢Trauma
Particularly intracapsular and subcondylar fractures
➢Infection
Local (ear, odontogenic, skin)
Systemic (osteomyelitis from long bones)
➢Systemic illness
Ankylosing spondylitis
Juvenile rheumatoid arthritis
Psoriasis
➢Radiotherapy
Parotid, bone and soft tissue tumours
➢Previous surgery to joint
 PATHOPHYSIOLOGY

TRAUMA

Extravasation of blood into the joint space

Haemarthrosis

Calcification and obliteration of the joint space

Intra-capsular ankylosis Extra-capsular ankylosis

 PATHOPHYSIOLOGY

Hematoma - endosseous vessels

Molecular pathways – expression of TGF, BMP

Activate osteoblasts

Bone formation

Rich anastomosis of capillaries penetrate the articular layer of condylar cartilage

and found lying just under the thin cortex in the young individuals
 CLASSIFICATIONS :

1. Bilateral or unilateral,

2. Fibrous or bony,

3. Intra articular or extra articular,

4. Complete or partial,

5. True or false.
 KAZANJIAN (1938)
INTRA-CAPSULAR ANKYLOSIS EXTRA-CAPSULAR ANKYLOSIS

➢ There is destruction of the meniscus

and flattening of the temporal fossa.

➢ Thickening and flattening of the condylar ➢ There is an external fibrous encapsulation

head and a narrowing of the joint space. with minimal destruction of the joint
itself.
➢ Opposing surfaces then develop fibrous
adhesions that inhibit normal
movements and finally, may become
ossified.
 CLINICAL HISTORY OF RELEVANCE

➢Time of onset
➢Severity
➢Duration
➢Unilateral or bilateral
 CLINICAL CONSEQUENCE
FUNCTION AND ➢Restriction of mandibular motion
ESTHETICS ➢Deviation of the mandible to
ankylosed side on opening
➢Impaired Speech

FUSION OF MANDIBULAR
CONDYLE TO BASE OF ➢Mandibular deficiency, bird fascies
SKULL “vogelgesicht”Facial asymmetry
➢Varying degree of malocclusion,
caries tooth, poor oral hygiene,
halitosis
PSYCHOLOGICAL STRESS
➢Hypertrophic suprahyoid
musculature
➢Compromised Airway
 ANTEGONIAL NOTCHING IN ANKYLOSIS

Digastric and Continous

Pterygomassetric
mylohyoid growth at angle
and Temporalis NOTCHING
contractions by subperiosteal
contractions
(pull downwards) apposition
(pull upwards)

WARPING Disrupted growth of

condyle
 INVESTIGATIONS

➢Radiographs - Plain film radiographs are of little value

➢ Panoramic radiographs may be beneficial
➢ Arthrography occasionally useful in demonstrating fibrous ankyloses but is
contraindicated in bony ankyloses
➢MRI imaging is also of little value
➢CT
 RADIOGRAPHIC FINDINGS

➢Decreased ramus height on the affected

side
➢The joint space is partially or completely
obliterated with dense sclerotic mass
➢Condyle can be replaced by shapeless
mass of bone
➢Prominent antegonial notch on the
affected side
➢Elongation of coronoid process
 CT
FINDINGS

Coronal CT showing bony exostoses in the

glenoid fossa superiorly as well as medial on
the condylar head, resulting in Bony
Ankylosis.

Axial CT scans of two different patients illustrating the

relationship of the ankylosed bone mass to the surrounding vital
structures at the base of the skull. C=Carotid canal;
Arrow=Foramen spinosum. Arrowhead=Foramen ovale
 SAWHNEY GRADING
PLAST RECON SURG 1986;77 :29-40
➢ Type I : Condylar head is flattened or deformed in close approximation to
the upper joint space. Dense fibrous adhesion is present within. Restricted
motion is due to fibrosis in and around the joint.

➢ Type II : Flattened condyle in close approximation to the glenoid fossa,

bony fusion of the outer (lateral) aspect of the articular surface either
anteriorly or posteriorly and limited to a small area.

➢ Type III : Ankylosis usually results from a medially displaced fracture

dislocation of the condyle with bone bridging the ramus of the mandible
to the zygomatic arch. The atrophic condylar head is either free or fused
to the medial aspect of the superior portion of the ramus.

➢ Type IV :A wider bony block bridges the mandibular ramus and

zygomatic arch, extending and obliterating the upper joint space and
completely replacing the architecture of the joint.
 RAVEH ET AL., 1989

Based on the extent of involvement of the articular fossa, median

structures and skull base.

➢Class I : Ankylotic bone tissue limited to the condylar process and articular fossa.
➢Class II : The bone extends out of the fossa involving the medial aspect of the skull base
up to the carotid- jugular vessel.
➢Class III : Extension and penetration into the middle cranial fossa.
➢Class IV : Combination of class II and III.
 SASHI AGGARWAL, MANORAMA BERRY ET AL 1990
(B ASED ON CT FINDINGS) 3 -0 . 1990 :69

➢Type I : Medially angulated condyle with deformed articular fossa and a mild to moderate amount
of new bone formation. Condyle can be identified – The articular fossa has corresponding
irregular, shallow or deep and usually sclerosed, the sclerosis extending to the adjacent areas of the
temporal bone.
(Aetiology specific – trauma associated)

➢Type II : Joint architecture completely disrupted with no recognisable condyle or articular

fossa. There are large masses of new bone, funnel shaped, extending from the thickened ramus to
the grossly sclerosed and irregular base of the skull.
(Sequelae of both trauma & non trauma cases)
 EL HAKIM & METWALLI CLASSIFICATION
(Relationship to ECA)

Class I: Includes unilateral and bilateral fibrous ankylosis. The condyle and glenoid fossa retain their original shape, and the
maxillary artery is in normal anatomical relation to the ankylosed mass.

Class II: there is unilateral or bilateral bony fusion between the condyle and the temporal bone. The maxillary artery lies in
normal anatomical relation to the ankylosed mass.

Class III: the distance between the maxillary artery and the medial pole of the mandibular condyle is less on the ankylosed
than in the normal side or the maxillary artery runs within the ankylotic bony mass. This is best seen on coronal CT.

Class IV: the ankylosed mass appeared fused to the base of the skull and there is extensive bone formation, especially from
the medial aspect of the condyle to the extent that the ankylosed bony mass is in close relationship to the vital structures at
the base of the skull such as the pterygoid plates, the carotid and jugular foramina and foramen spinosum and no joint
anatomy can be defined from the radiograph. This is best visualized on axial CT.
 HE ET AL CLASSIFICATION
J ORAL MAXILLOFAC SURG 69:1600-1607,
2011 A2
➢A1: Fibrous ankylosis without a bony component,

➢A2: Bony ankylosis in lateral joint, residual condylar

fragment is larger than 50% of contralateral normal
condyle,
A3

➢A3: Similar to A2 but residual condylar fragment is

smaller than 50% of contralateral normal condyle,

➢ A4: Complete bony ankylosis. A4

 CDA CLASSIFIC ATION

‘C’ – Condylar head could be preserved

• Co -- Lateral Bony Ankylosis of both joints with the
medially displaced condylar heads preserved
• C1 -- Ankylosis of the entire joint presenting with
bony fusion and no recognizable condyle or
fossa on one or both sides
‘D’ – Any Secondary Facial Deformity
• Do – No significant Dentofacial Deformity
• D1 -- Dentofacial Deformity affecting occlusion and facial profile
‘A’ – Skeletal Age of the patient
• Ac – Young patient with active dentofacial growth (skeleton immature)
• Aa – Adult patient with fully developed dentofacial structure (skeleton mature)
TREATMENT STRATEGIES USING CDA CLASSIFIC ATION
 OBJECTIVES OF TREATMENT FOR ANKYLOSIS :

➢To improve joint movement and function, which requires meticulous and radical
removal of the ankylosed bone or creation of pseudo joint.

➢To prevent recurrence of the ankylosis. This is by means of active postoperative

physiotherapy, interpostional substances to prevent reankylosis.

➢To restore occlusion.

➢To correct and restore the secondary facial deformity.

 KABAN’S PROTOCOL – PERROT & FISCHER

J oral maxillofac surg.. 1990 Nov;48(11):1145-51.

. 2009 Sep;67(9):1966-78. Kaban,Bouchard &Troulis
J Oral Maxillofac Surg

1. Aggressive excision of fibrous and/or bony mass

2. Coronoidectomy on affected side
3. Coronoidectomy on opposite side if steps 1 and 2 do not result in MO of 35 mm
4. Lining of joint with temporalis fascia or the native disc, if it can be salvaged
 KAB AN ’S P ROTO C OL – P E R ROT &F I S C HE R
J O R A L MA XIL L O FA C SU R G . . 1 9 9 0 N O V;4 8(11):11 45 -5 1.
J O R A L MA XIL L O FA C SU R G . 2 0 0 9 S E P ;6 7 (9):19 66 -78 . K AB AN , B OUCHARD
&TROUL IS

5. Reconstruction of resected condyle unit with either distraction osteogenesis or

costochondral graft and rigid fixation
6. Early mobilization of jaw;
❑ If distraction osteogenesis used to reconstruct resected condyle unit,
mobilize on day of surgery.
❑ If costochondral graft used,
early mobilization with minimal intermaxillary fixation (not
more than ten days).
7. Aggressive physiotherapy.
 SALINS (2000) CONCEPT

Salins in 2000 gave a new perspective in the management of the ankylosis by performing
an osteotomy inferior to the ankylotic mass (subankylotic approach) and
producing a pseudoarthrosis.

The author advocates use of temporalis muscle flap and interpostional substance of 7
to 8 mm thick to prevent reankylosis.
 Salins (2000) concept
This technique differ from conventional technique in the following aspect :
➢The ankylotic mass is not resected / manipulated.
➢Bone is not removed to create a gap as in the case of gap arthroplasty.
➢A functional pseudoarthrosis is created between normal bone surfaces.

➢The advantages of this technique include :

➢A pseudoarthrosis is encouraged to form in normal bone below the base of the ankylotic
mass.
➢Since thin ridges of normal bone border the gap created with this technique, scar tissue
formed is minimal and an effective interposition arthroplasty is made possible.
➢There is no bone sacrifice to create a gap, therefore no reduction in ramal length.
 ESMARCH PROCEDURE

Esmarch's report in 1860 describing the removal of a wedge shaped piece

of bone from the ascending ramus. Advocated the use of surrounding muscles
into this area of excision.
 DISTRACTION OSTEOGENESIS

➢The use of distraction osteogenesis (DO) has been described for reconstruction of the
excised segment.
➢In this instance the condylar segment is excised as normal but a cortical osteotomy is
performed.
➢A mini distractor is placed and active distraction commences after a two to four day latency
phase. Distraction proceeds at rate of 1 mm per day until the neo condyle makes contact
with the skull base.
➢The advantages of this technique include the lack of donor site morbidity as well as the
potential to begin rehabilitation of the joint immediately following surgery.
➢The disadvantages of DO include the risk of infection as well as failure of distraction.
Additionally, the proximal ‘condyle’ lacks a growth centre conferring a risk of developing
mandibular asymmetry and malocclusion.
 SURGICAL PROCEDURES

➢Condylectomy

➢Gap arthroplasty

➢Interpositional arthroplasty – advocated by Verneuil 1860

 MATERIALS FOR INTERPOSITIONING

I. Autogenous III. Alloplasts

a. Cartilaginous grafts a. Metallic
. Costochondral . Tantalum foil
. Metatarsal . Stainless steel
. Sternoclavicular . Titanium
. Auricular cartilage . Gold
b. Temporal muscle b. Non-metallic
c. Temporal fascia . Silastic
d. Fascia lata . Teflon
e. Dermis . Nylon
II. Heterogenous . Acrylic
a. Chr. submucosa of pig bladder . Proplast
b. Lyophilised bovine cartilage . Ceramic
 ACCESS FOR SURGERY

EXTRAORAL INTRAORAL VESTIBULAR

Preauricular Without endoscope

Endaural With endoscope

Postauricular

Coronal, Hemicoronal

Retromandibular

Submandibular

Rhytidectomy
 INCISIONS

Risdon’s Blair’s
Submandibular Inverted Dingman’s Thoma’s Popowich & Crane
Hockey Preauricular Angulated

Alkayat and
Aleaxander and James Hind’s Postramal Lamport’s Bramley
Post auricular Endaural
 ANCILLARY BUT CONTROVERSIAL

➢The heterotropic ossification can be prevented by medical therapy and

radiotherapy.
➢The medical therapy - Antiresorptive agents like biphosphonates
(sodium etidronate, pamidronate and allendronate).
➢Radiation of up to 5oooGcy has been advocated to prevent
osteoblasts from depositing osteoid.
 POST OP MEASURES

➢In the immediate postoperative phase, a strict soft diet is recommended.

➢The rehabilitation phase should commence as soon as practically possible.

➢This includes frequent active range exercises as well as manual stretching.

➢These exercises should be performed frequently (four to five times per day) for
several minutes at a time.

➢Patients should be seen frequently in the outpatient clinic for follow-up.

ARAKERI CONCEPT
 ARAKERI’S TMJ RELEASE TECHNIQUE

Med Hypotheses. 2012 May;78(5):682-6. doi: 10.1016/j.mehy.2012.02.010. Epub 2012 Mar 9. PMID: 22406097.
MANAGEMENT OF
TRIAD
PATIENTS
MODIFIED KABAN PROTOCOL
 TREATMENT OF TEMPOROMANDIBULAR
JOINT ANKYLOSIS WITH TOTAL JOINT
RECONSTRUCTION
ORAL MAXILLOFACIAL SURG CLIN N AM 27 (2015) 27 –35
Mean follow-up 50.4 months. Reza Movahed, DMD, Louis G. Mercuri, DDS, MS
Results
52% reduction in pain, and
improvement in jaw
function (76%), diet (72%), and
maximum incisal
opening (MIO) (140%) from
11.75 mm to
32.9 mm, whereas 17 of 20
patients (85%) re-
ported improvement
in quality-of-life scores
Mercuri and colleagues evaluated 20 patients
with 33 reankylosed TMJs managed with patient- Wolford and Karras published the first study evaluating fat
fitted TMJ TJR devices and placement of periartic- grafts placed around TMJ total joint prostheses.
ular autogenous abdominal fat grafts.
 REFERENCES

➢ Textbook of Association of Oral and Maxillofacial Surgeons of India , Chapter 65 ; Sonal Anchila p 1401-35
➢ Andrade NN, Nerurkar SA, Mathai P, Aggarwal N. Modified Cut for Gap Arthroplasty in Temporomandibular
Joint Ankylosis. Ann Maxillofac Surg. 2019 Jul-Dec;9(2):400-402. doi: 10.4103/ams.ams_269_18. PMID:
31909023; PMCID: PMC6933955.
➢ Kaban LB, Bouchard C, Troulis M. A protocol for management of temporomandibular joint ankylosis in children.
J Oral Maxillofac Surg 2009; 67(9): 1966–78.
➢ Kundra P,Vasudevan A, Ravishankar M.Video assisted fiberoptic intubation for temporomandibular ankylosis.
Pediatric Anaesthesia 2006;16: 458–61.
➢ Dean A, Alamillos F. Mandibular distraction in temporomandibular joint ankylosis. Plast Reconstr Surg 1999;
104: 2021.
➢ R. Gunaseelan: Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using
resected segment as autograft. A new technique. Int. J. Oral Maxillofac. Surg. 1997; 26: 405-407.
 REFERENCE

Yan et al. Head & Face Medicine 2014, 10:35 http://www.head-face-med.com/content/10/1/35

THANK YOU