ANKYLOSIS OF ANKYLOSIS OF TEMPOROMANDIBULAR TEMPOROMANDIBULAR

JOINTJOINT

•Definition:- Ankylosis refers to the partial or compete inability to open

the mouth which results in functional

and growth deformation of the

mandibe.

ANATOMY OF TMJANATOMY OF TMJ

TMJ is highly specialised ,diarthroidal non weight bearing synovial joint of condylar variety

ARTICULAR SURFACES:- upper surface :- a) articular eminence b) anterior part of the mandibular fossa lower surface:- Head of the mandible

BONY COMPONENT:-

º consist of glenoid fossa of the temporal bone & mandibular condyle.

º condyle is roughly elliptical in cross section with mediolateral width being two times the anteroposterior width.

º the glenoid fossa is a smooth depression in the temporal bone which is thinnest in its deepest part which separates the joint from the middle cranial fossa.

º articular surface is covered by fibrocartilage.

SOFT TISSUE COMPONENT:-1) Intraarticular disc or meniscus2)Synovial membrane3) Lateral pterygoid muscle4)Capsule of joint5) Ligaments- a) temporomandibular (lateral) ligament b) sphenomandibular ligament c) stylomandibular ligament d) anterior malleolar ligament

NERVE SUPPLY:- 1) articulotemporal nerve 2) masseteric branch of mandibular nerve BLLOD SUPPLY:- 1) superficial temporal branch of external

carotid artery 2) middle meningeal artery

APPLIED PHYSIOLOGYAPPLIED PHYSIOLOGY Movement produced by muscle of

mastication in the upper joint cavity gliding movements and in the lower joint cavity hinge movements take place.

movements are:- - Protrusive -Retraction -Depression -Elevation -Lateral or side to side movements

CLASSIFICATIONCLASSIFICATIONKazanjian(1938) 1.True(intraarticular):- fibrous or bony adhesion between the articular surfaces of TMJ.

2. False(extraarticular):- Results from pathologic condition outside the joint,

that results in limited mandibular mobility.

Another classification.

.

A 1. Fibrous 2. Fibroosseous 3. Bony

B 1. Partial 2. Complete

ETIOLOGYETIOLOGY1. TRAUMA- Most common cause of

ankylosis. Trauma to the chin forcing the condyle against the glenoid fossa, particularly with bleeding into the joint.

2. INFECTION- From middle ear & mastoid (otitis media,mastoiditis).

3. INFLAMMATORY- . primary inflammation of the joint . secondary to local inflammatory process. (osteomyelitis) .Secondary to blood streaminfections - septicemia - scarlet fever - gonorrhea . Rheumatiod arthritis

4.NEOPLASTIC - (osteochondroma)

5.CONGENITAL

6.MYOGENIC – Myositis ossificans produce limited opening.

7. NEUROGENIC – epilepsy,brain tumour.

CLINIC FEATURESCLINIC FEATURES• It includes – . General features . Unilateral features . Bilateral features

GENERAL FEATURESGENERAL FEATURES• AGE- Seen in young age (1 to 10 years)• Symptoms – Trismus (inability to open mouth). Oral problems – poor oral hygiene carious teeth periodontal problems malocclusion

UNILATERAL FEATURESUNILATERAL FEATURES1. Mouth opening is very limited 2. Asymmetry of face with fullness

of the affected side & relative flattening of the unaffected side.

3. Face is deviated towards the affected side.

4. Chin is retracted on the affected side & slightly bypass the midline.

5. Slight gliding movement towards the affected side.

6. Cross bite is present.

7. Well defined antegonial notch on affected side.

BILATERAL FEATURESBILATERAL FEATURES• Bird face appearance/

micrognathia.

• No gliding movement neither protrusive nor lateral movement.

• Presence of scar on the chin (possibly due to trauma)

• Class II malocclusion, protrusive incisors & anterior open bite.

• In a long standing case there is atrophy or fibrosis of muscle.

• In congenital case-difficulty of introducing the nipple into the mouth of newborn infants.

HISTOPATHOLOGYHISTOPATHOLOGY1. Atrophy or destructive changes in the

cartilagenous component of the joint with loss of meniscus.

2. Normal soft tissue is replaced by thick fibrous bands.

3. An overall flattening of articulation.4. Glenoid fossa & articular eminence

become less pronounced.5. The condyle become enlarged, composed

of dense sclerotic bone.

INVESTIGATIONSINVESTIGATIONS• For definitive diagnosis & to confirm the

extent of bony growth imaging may be required.

1. Lateral oblique view 2. O. P. G. view 3. Cephalometric radiograph 4. Submentovertex view 5. PA view 6. C T Scan

• FINDINGS – 1. Decreased ramus height on

the affected side.

2. The joint space is completely or partially obliterated with dense sclerotic bone.

3. The condyle can be replaced by shapeless mass of bone.

4. Prominent antegonial notch on the affected side of mandible.

5. Elongation of coronoid process.

6. Sometimes A transverse or oblique dark line crossing the mass of dense bone showing fibrous ankylosis.

MANAGEMENTMANAGEMENT• Ankylosis can only be treated

surgically there is no form of pharmacological management.

• The type of surgery depends on the patient & extent of deformity.

• Treatment also varies if ankylosis is unilateral or bilateral.

Surgery for ankylosis is done in two stages

1. in first operation only a release of ankylosis is done, Jaw mobility is brought about.

it is belived that growth takes place after ankylosis release.

2. Second procedure, an orthognathic surgery can then be planned to restore facial esthetics. (especially in children)

GOALS OF TREATMENTGOALS OF TREATMENT1. To create mobility in the joint to a

satisfactory limit.2. To restore vertical height of the ramus.3. To restore the mandible & TMJ to normal

anatomic & functional state.4. To create a new joint space.5. To allow the jaw to grow normally in child

treated for ankylosis.6. To restore the facial esthetics.7. To prevent recurrence of ankylosis.

SURGICAL PROCEDURESSURGICAL PROCEDURESIt includes 1. Condylectomy 2. Gap Arthroplasty 3. Interpositional Arthroplasty

CONDYLECTOMYCONDYLECTOMY• This is a procedure done in ankylosis where

the anatomic feature of the joint are not completely changed as in areas of fibrous.

• COMPLICATIONS- 1.Loss of vertical height of ramus

2. in bilateral condylectomy it create an anterior open bite.

3. In unilateral condylectomy there is deviation of the jaw on opening.

GAP ARTHRPLASTYGAP ARTHRPLASTY• Gap arthroplasty involves creation of an

anatomical gap in the ankylosed segment to form an artificial joint space.

• The gap is created at a level lower than the original joint space.

• Two horizontal bony cuts are made in the most superior aspect of the ramus and the wedge of bone.

• A gap of 1-1.5 cm. is created & first interposed with any material.

• COMPLICATIONS- 1. Chances of creating excessive gap

& reducing vertical height of ramus.

2. Anterior open bite due to excessive bone removal.

3. Reankylosis due to bony contact b/w the cut ends.

INTERPOSITIONAL INTERPOSITIONAL ARTHROPLASTYARTHROPLASTY

• Placing the interpositional material material b/w the two cut ends avoids contact b/w the bony ends.

• It minimises the chance of reankylosis.

• I.P. material may be- biological- dermis, facia lata, bone &

cartilage. Alloplastic- Vitallium, Tantalum,Silastic & Acrylic.

COMPLICATIONS- 1. Second surgical site is

necessary. 2. Foreign body reaction to

alloplastic material. 3. Difficulty in suturing or stablizing

the interpositional material on the medial aspect of joint.

4. Doner site complication such as pleuritic pain, pneumothorax.

SURGICAL APPROACHSURGICAL APPROACH• Preauricular approach• Risdon’s submandibular

approach• Temporal approach• Post auricular approach• Endural approach• Retromandibular approach(post

ramus)

OPERATION BY TEMPORAL OPERATION BY TEMPORAL APPROACHAPPROACH

1.It is the approach through a curvilinear preauricular incision, extending 3 cm. long into the temporal region for the exposure of temporal facia.

2.The dissection of soft tissue is proceeded up to zygomatic arch.

3.The capsule of the joint is opened with a T shaped incision of the facia.

4.Once the joint region is exposed and ankylosed site is identified, aggressive excision of the fibrous & bony mass carried out.

5. Special attention is directed to the medial extension of the callus to ensure adequate excision.

6. Glenoid fossa is recontoured as needed.

7. Coronoidectomy & stripping of muscles are done.

8.It is observed that nearly 1/3 of the height of the ramus is lost following condylectomy & coronoidectomy.

9.Costochondral graft is removed through inframammary incision.

10.Through submandibular approach ramus is exposed.

11.Masseter & temporalis are stripped from the ramus.

12.Then the surface of the graft and ramus are freshened to produce good bony interface.

13.The graft is placed in position & fixed with stable internal fixation so that 2mm. of posterior open bite is created to compensate for remodelling of the costochondral graft.

14.The length of the graft is determined by the ramus height discrepancy & the facial asymmetry to be corrected.

15. A drain is placed & the wounds are closed in layers.

16. After inter maxillary fixation for a few days, jaw is mobilized vigorously & physiotherapy is continued.

MANAGEMENT MANAGEMENT SUGGESTED SUGGESTED

PROTOCOL(KABAN’S)PROTOCOL(KABAN’S)1.Aggressive total excision of the

ankylotic segment in condylar/TMJ region, incomplete removal, particularly medial aspect result in recurrance.

2.Dissection & stripping of muscles of mastication of the ramus & ipsilateral coronoidectomy are essential.

3. Inter incisial opening should be critically evaluated to ensure that it

should be more than 35 mm.4. If step 1,2,3 do not create enough

opening opposite side coronoidectomy is done.

5. A suitable interpositional material must be placed to avoid the risk of reankylosis.

6. Reconstruction of ramus with costochondral graft helps to maintain

the ramus height.

7. Rigid fixation of the graft with ramus is necessary for early mobilization of the joint.

8. Creation of open bite on affected side to permit setting of graft for 3-6 months.

9. Early mobilization with minimum IMF less than 3 weeks.

10. Post operative physiotherapy 6-8 weeks.

11.If no further improvement is noticed postoperatively, joint is stretched under GA.(Brisement Force given.)

12.Later on, if needed, excessive growth of the costochondral graft may have to be recontoured so that no disturbance in occlusion & jaw relationship develop.

REASONS OF REASONS OF RECURRENCERECURRENCE

1.Incomplete excision of callus at the ankylosed site.

2.If the mouth opening during surgery is less than 35 mm & if coronoid process is not excised, recurrence develops.

3.Insufficient & unsatisfactory physiotherapy.

4.Failure to maintain the ramus height leads to narrowing of the inter- fragmentory gap.

5.Failure to provide a satisfactory interpositional material.

6.Heigher osteogenic & periosteal reaction may be responsible for high rate of recurrence in children.

COMPLICATION OF COMPLICATION OF ANKYLOSIS RELEASE ANKYLOSIS RELEASE

SURGERY SURGERY A. Preoperative consideration B. Intra operative consideration a. complication due to incision b. complication during

osteotomy procedure. c. Postoperative complications.

COMPLICATIONS DUE TO COMPLICATIONS DUE TO INCISIONINCISION

1. Damage to facial nerve.

2. Bleeding from superficial temporal artery or facial vessels.

3. Damage to parotid gland.

COMPLICATIONS DURING COMPLICATIONS DURING OSTEOTOMYOSTEOTOMY

1. Inadequate bone removal

2. Profuse bleeding from maxillary artery, pterygoid venous plexus

3. Perforation of middle cranial fossa by damage to glenoid fossa.

POSTOPERATIVE POSTOPERATIVE COMPLICATIONSCOMPLICATIONS

1. Anterior open bite or deviation of jaw.

2. Infection to surgical site.

3. Reankylosis.

4. Frey’s syndrome.

MANAGEMENT SUMMARYMANAGEMENT SUMMARY1.Prior to 1951, it was considered to be

incurable.2.Brisment force (forceful opening

under GA) was tried without success.3.Esmarch suggested- wedge resection

of the body of the mandible.4.Condylectomy in early cases.

5. gap-arthroplasty led to recurrance.

6. osteoarthrotomy(gap & interpositional

arthroplasty) improved the prognosis.

7. Excision of callus & joint reconstruction become the treatment of choice.

R E F E R E N C E SR E F E R E N C E S• B. SHRINIVASAN – Text book of oral &

maxillofacial surgery. (second edition)

• CHITRA CHAKARWARTI - Text book of oral & maxillofacial surgery. (first edition)

• ANIL GOVINDRAO GHOM- Text book of oral medicine. (first edition)