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.

3. MYOSITIS OSSIFICANS• When there is hematoma formation & progressive

ossification after injury and especially of the masseter muscle, inability to open the mouth develops.

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

UNILATERAL ANKYLOSIS1. Facial asymmetry with affected side appearing

normal & the opposite side appearing flat.

2. 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.

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

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 . 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 theexternal auditory meatus at

the superiormental 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 MATERIALSCartilagenous

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 67:1966-1978, 2009

  Louis G. Mercuri : Total Joint

ReconstructiondAutologous or Alloplastic : Oral Maxillofacial Surg Clin N Am 18 (2006) 399–410.

 

Thank you