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 ankylosis.


in contrast when the disease involves the TMJ itself, it is called "true ankylosis. 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

ETIOPATHOLOGY OF FALSE ANKYLOSIS  MUSCULAR TRISMUS It can be established because of pericoronitis, infection adjoining the muscles of mastication involving submasseteric ,pterygomandibular, infra - temporal or submandibular spaces.
 2. MUSCULAR FIBROSIS

Muscular fibrosis from long standing dysfunction like a arthritis and myositis etc. hampers the jaw movements. When there is hematoma formation & progressive ossification after injury and especially of the masseter muscle, inability to open the mouth develops.

 3. MYOSITIS OSSIFICANS

 4. TETANY

When there is hypocalcaemia, the spasms in the muscles are produced hampering the opening of the mouth.  5. 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. NEUROGENIC CAUSES Neurogenic causes like epilepsy, brain tumour, and hemorrhage in medulla oblongata are also represented by hypomobility of the jaw.  7. TRISMUS HYSTERICUS It is disease of psychogenic origin.

 8.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.

 9. 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.

ETIOPATLOGY OF TRUE ANKYLOSIS

 Birth trauma producing so-called congenital ankylosis and occurs in cases of

difficult delivery, particularly forceps delivery.



Haemarthrosis is another cause of ankylosis. It is generally, due to: fracture of the base of skull extending through the mandibular fossa

may also be caused by an intracapsular injury.

 Suppurative arthritis, may be due to infection of the ear or mastoiditis leading to

ankylosis
 Rheumatoid 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

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

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

1.

UNILATERAL ANKYLOSIS Facial asymmetry with affected side appearing normal & the opposite side appearing flat. Chin is deviated to the ankylosed side. This is because the normal side continues to grow & pushes the mandible to the affected side giving appearance of fullness on the ankylosed side.

2.

3.

Prominent Ante-gonial notch on the affected side

DIAGNOSIS BASED ON
 . History of infection or trauma

(birth trauma + falls + previous infection of the ear)

 2. Findings at clinical examination

(reduced interincisal opening + diminished/no TMJ movements + scar on the chin due to trauma)

 3. Radiological findings

FOR PROPER EVALUATION SEVERAL RADIOGRAPHS ARE USEFUL Orthopantomograph: OPG will show both the joints for comparision and in unilateral cases will also reveal ante-gonial notching.

PA view will show the mediolateral extent of the bony mass also reveal any mandibular asymmetry.

Lateral oblique will demonstrate the antero-posterior extent of the bony mass and the elongation of the coronoid process  CT Scan/3D CT Scan gives relationship to the middle cranial fossa and internal carotid artery (carotid canal) medially to the ankylotic mass usually not seen in conventional radiographs 3D CT SCAN showing Bony ankylosis

 CONE BEAM 3D CT SCAN The 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.  elongation of coronoid process.  Sometimes a transverse or oblique dark line crossing the mass of dense bone is

seen showing fibrous ankylosis

KABANS 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 .  Lining of joint with temporalis fascia or the native disc, 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, mobilize day of surgery; if CCG used, early mobilization with minimal intermaxillary fixation (not more than 10 days)  Aggressive physiotherapy

SURGICAL APPROACHES TO TMJ

    

1. Preauricular incision with modifications 2. Submandibular incision 3. Post auricular 4. Post ramal 5. Endaural incision

PRE-AURICULAR INCISION & ITS MODIFICATIONS

ALKAYAT - 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

Submandibular approach
 Two locations of submandibular

incisions. Incision A parallels the inferior border of the mandible. Incision B parallels or is within the resulting skin tension lines. Incision B makes a less Conspicuous scar in most patients.  the incision should be 1.5 to 2 cm inferior to the anticipated location of the inferior border.

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.  The incision is now continued inferiorly, with the knife in continuous contact with the tympanic plate, to make a semicircular incision to the inferior point of the meatus.

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, fibre-optic or retrograde intubation may need to be employed. Only when it is not possible to intubate with these procedures should a tracheostomy be considered. Blood loss may be significant at the time of surgery especially in children & there should be plans for blood transfusion.

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. In the second stage surgery an orthognathic surgery can be planned to restore facial esthetics. 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.

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

 Disadvantage

 Procedure

GAP ARTHROPLASTY

 First done by abbe  Indications :

In extensive bony ankylosis

 Technique  Disadvantages  Complications

INTERPOSITIONAL ARTHROPLASTY  To prevent re-ankylosis after gap arthroplasty insertion of an interpositional material is advocated.
 If the disc of the joint is found the disc is mobilized & positioned to cover

the glenoid fossa.

 Numerous materials have been used as interpositional material for

temporomandibular joint to prevent re-ankylosis, but the temporal fascia is the most widely used interpositional material. Requirements for interpositional material  Biologically and chemically inert  Noncarcinogenic  Adaptable to molding at operative site  Strength and rigidity.

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

TOTAL JOINT RECONSTRUCTION  Recurrent fibrosis or bony ankylosis not responsive to other modalities of treatment .
 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 vitek  Christensen type I  Christensen type II

HOW WE HAVE TO SELECT THE RECONSTRUCTIVE MATERIAL DEPENDING ON THE CONDITION ?

 Traditionally, complete bony TMJ ankylosis has been managed with gap

arthroplasty with autogenous tissue graft or alloplastic reconstruction. Although the autogenous grafting techniques develop form, mandibular function is typically delayed. Because graft mobility during healing compromises its incorporation with the host environment or its blood supply, early mandibular mobility often leads to graft/host interface failure.
 For the patient who has reankylosis, placing autogenous tissue such as bone into

an area where reactive or heterotopic bone is forming is not logical.

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.Quinn

References
 P. J. Leopard : Surgery of the non-ankylosed temporomandibular joint : British journal of

oral and maxillofacial surgery 1987: 25: 138-148.

 Rowe NL. Ankylosis of the temporomandibular joint. J R Coll Surg Edinb 1982; 27: 67

79.
 Leonard B. Kaban, Carl Bouchard and Maria J. Troulis : A Protocol for Management

Of Temporomandibular Joint Ankylosis in Children : J Oral Maxillofac Surg 67:19661978, 2009

 Louis G. Mercuri : Total Joint ReconstructiondAutologous or Alloplastic : Oral

Maxillofacial Surg Clin N Am 18 (2006) 399410.

Thank you