Temporo-Mandibular Joint Disorders (TMD)

Part III

Dr. Gaurav Sharma P.G. Part III

Contents• TemporoMandibular Joint Ankylosis• TemporoMandibular Joint

Hypermobility.

TemporoMandibular Joint Ankylosis

• Definition :Inability to open the mouth beyond 5-10mm of inter-incisal opening due to fusion of head of the condyle of the mandible with the articulating surface of the glenoid fossa.

• Ankylosis, or Anchylosis from Greek bent, crooked.

Classification

1. False ankylosis or True ankylosis. 2. Extra - articular or Intra - articular. 3. Fibrous or bony.4. Unilateral or bilateral.5. Partial or complete.

Etiology

False Ankylosis :

1. Muscular Trismus :2. Muscular Fibrosis :3. Myositis Ossificans :

4. Tetany :5. Tetanus :6. Neurogenic Causes :7. Trismus Hystericus :8. Drug Induced :

9. Mechanical Blockade :10. Fracture of the Zygomatic Arch :11. Fracture of Mandible :12. OSMF :

True Ankylosis :

Classified as: • Fibrous Ankylosis. • Fibro - osseous Ankylosis.• Bony Ankylosis. Further, it may be unilateral or bilateral and partial or complete.

Etiology

1. Birth Trauma :2. Haemarthrosis :3. Suppurative Arthritis :

4. Rheumatoid Arthritis :5. Osteomyelitis :6. Fracture of the condyle :

CLINICAL FEATURES

Clinical manifestations vary according to: Severity of ankylosis. Time of onset of ankylosis. Duration.

• Pain. • Reduced mouth opening .• Difficulty or inability in mastication.

food.

Features :• Receding chin. • Malocclusion.• Multiple Impacted teeth. • The maxilla may be narrow

and protrude.• Ante - gonial notching.

In Bilateral Ankylosis :• Bird face deformity + micro

gnathic mandible• Inability to open mouth +

inability to masticate• Class II malocclusion• Ante - gonial notching• Poor oral hygiene • Severe malocclusion with

crowding + protrusive upper anterior teeth + anterior open bite

In Unilateral Ankylosis :

• Facial asymmetry with affected side.• Chin is deviated to the ankylosed side.• Ante-gonial notch on the affected side• Minimal condylar movements on

palpation.• Class II malocclusion on affected side

and cross bite may be seen

Problems associated with Ankylosis

1. Interferes with the mastication of food and with nutrition2. Prevents oral hygiene and prophylactic care.3. Dental care.4. Absence of normal development of the jaw .5. Disturbance of normal eruption of the teeth.

Diagnosis

Diagnosis is based on: 1. History of infection or trauma2. Findings at clinical examination3. Radiological findings

Radiographic Examination

• Orthopantomograph

• PA Mandible

• Lateral view of Mandible

• CT Scan/3D CT Scan

3D CT SCAN showing Bony Ankylosis

Coronal CT Scan showing Bilateral TMJ Ankylosis

• Cone Beam 3D CT Scan

In fibrous ankylosis :• Evidence of destructive.• Proliferative changes seen in bony compartments of

TMJ.• Haziness or narrowing of joint space.

In bony ankylosis :• Overall obliteration of joint space.• Antegonial notching anterior to the angle of mandible.• Elongation of coronoid process.

What happens if Ankylosis is left untreated ?

Normal growth & development of face is affected.

Nutritional impairment. Speech impairment. Sleep apnoea in Bilateral Ankylosis. Malocclusion. Poor Oral hygiene. Multiple Carious and Impacted teeth.

MANAGEMENT OF ANKYLOSIS

Aims and Objectives of Surgery

1. Release of ankylosed mass and creation of a gap to mobilize the joint.

2. Creation of a functional joint. - To improve patient's nutrition.

- To improve patient's oral hygiene.- To carry out necessary dental treatment.

3. To reconstruct the joint and restore the vertical height of the ramus.

4. To prevent recurrence. 5. To restore normal facial growth pattern

6. To improve esthetics and rehabilitate the patient.

Pre – Surgical Considerations

Techniques such as blind nasal, fibre-optic or retrograde intubation may be employed.

Blood loss may be significant at the time of surgery especially in children.

KABAN’S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS

1.Early surgical management.2.Aggressive total excision of the ankylotic

mass.3.Coronoidectomy + myotomy on the affected

side to eliminate temporalis muscle restriction.

4.Lining with temporalis muscle/fascia5.If steps 1 + 2 + 3 do not create enough

opening, opposite side coronoidectomy is done.

6.Reconstruction of Ramal height with

Costochondral graft.

7. Early post-operative mobilisation and aggressive

physiotherapy for at least 6 -12 months.

8. Regular long term follow-up.

9. Esthetic /orthognathic surgery to be carried out as

a secondary procedure, when growth has

completed.

SURGICAL PROCEDURE

Surgical Procedures :

1. Use of Brisement Force.2. Condylectomy.3. Gap Arthroplasty.4. Interpositional Arthroplasty.

Use of Brisement Force• Oldest method. • The jaw is forced open by

means of a mouth gag and mobilized as much as possible by forceful manipulation.

• Indicated in Fibrous Ankylosis or immobility caused by muscle spasms or fibrosis. Spring loaded Bell Excerciser

Condylectomy and Arthroplasty • Esmarch 1851

• Murphy 1913 • Blair 1928

Condylectomy

Indication:

1.Degenerative inflammatory Disorders.2.Malunited condylar fractures with limitation of

motion and pain during mastication.3.Terminal Stages of Internal Derangement.4.Fibrous Ankylosis.

CondylectomyPatient Preparation :1> Temporal shaving.2> Patient placed in supine position with head ring.3> Anaesthetic is safely secured.4> Face is left clear of the other drapes. 5> Ear canal is cleansed and covered.

Approach :

1> Capsule is opened via an inverted L incision.2> Anterior and posterior borders of the condylar neck.

Removal of Ankylotic mass :

• Cut is marked in a 45° angle from the sigmoid notch to the posterior border of the ramus.

• Osteotomy is completed on the lateral cortex, and the inner cortex is left intact .

• Pulling of the fragment not to be attempted.

• Dissection around the mass anteriorly and posteriorly.

• Bone mass now can be removed in total or in piecemeal.

• Cronoidectomy is done if indicated.

• Smoothening of all the bone surfaces.

• Haemostasis is achieved.

• IMF done after achievement of occclusion.• Edentulous patients Gunning splints is be

used.• Decision of Reconstruction is now taken.

Complications

• Loss of vertical height of the ramus.

• In case of bilateral condylectomy, it may create an anterior open bite.

• In unilateral cases, there may be deviation of the jaw on opening.

Gap Arthoplasty

• Bone of about 1.5 to 2 cm in width is removed.• Care should be taken while removing bone from

the medial aspect of the TM Joint.• Mouth is opened to check the opening 1.5 - 2

cms & not interposed with any material.• Post-op, this gap is maintained by active

physiotherapy to prevent re-ankylosis.• It may be necessary to osteotomise the

coronoid process also.

Interpositional Arthroplasty• Interpositional arthoplasty is similar to the gap

arthroplasty but the Gap is Filled by a Interpositional Graft.

• Alloplastic Materials : Metallic – Tantalum Plate, Titanium, Gold. Non Metallic – Silastic, Teflon, Acrylic, Ceramic.

• Autogenous Materials : Temporalis muscleTemporalis fascia,Skin grafts.Auricular cartilage.

Reconstruction of TMJ

Alloplastic Prosthesis

• Kent-Vitek• Synthes• Derlin-Timesh• Christensen• Biomet -Lorenz

Kent-Vitek

Synthes

Derlin-Timesh

Christensen

Biomet-Lorenz

Postoperative Care

1> Pressure dressing is applied by Dynaplast .

2> The patient is kept on Antibiotic therapy for 7 to 10 days.

3> Immobilization of the jaw by means of intermaxillary elastics is recommended for the first 7- 10 days.

4> Patient is given Physiotherapy.

Postoperative Physiotherapy

• Important Phase of Treatment . • Patient should be encouraged to start

active exercises of the jaws as soon as it can be tolerated.

• A mouth gag can be used for forceful mouth opening at a later stage.

• Medications can be given to relieve pain and enable movement.

• Heat application.

ComplicationsDuring Anaesthesia :

1.Aspiration of blood clot or foreign body during extubation as throat cannot be packed prior to surgery.

2.Danger of falling back of tongue and obstructing airway.

During Surgery :

• Hemorrhage.• Damage to External Auditory Meatus.• Damage to Zygomatic and temporal branch of facial

nerve.• Damage to Glenoid fossa and thus perforation into

Middle Cranial Fossa.• Damage to Auriculotemporal nerve. • Damage to Parotid gland.

During Post Operative Period :

1.Infection.2.Open bite.3.Recurrence of Ankylosis.

TemporoMandibular Joint Hypermobility and Dislocation

TMJ Hypermobility

Definition :A self reducing partial dislocation of TMJ, during which condyles passes anterior to the articular eminence. Peterson’s Principal of OMFS Vol 2, Pg No. 1044 .

Etiology

• Yawning.• Vomiting.• Wide biting.• Seizure Disorders.• Trauma:Intubation during General Anaesthesia.Endoscopy.Prolonged Dental procedure.

• Connective Tissue Disorders :Ehlers-Danlos Syndrome.Marfan Syndrome.• Internal Disc Derangements..

Management

• Conservative Management:Prolotherapy.Immobilisation of Jaws.• Surgical Management :Capsule Tightening Procedure.Creation of Mechanical Obstruction.Eminectomy.

Conservative Management

Prolotherapy• Hackett 1939.• Mechanism of Action :• Re initiation of inflammatory

process leading to fibroblast proliferation.

• Most commonly used agents :• Sodium Tetradecyl Sulphate • Sodium Morrhuate.• 12 % Dextrose Solution.

Frequency of Injection

Two-week, four-week, and six-week intervals, resulting in four injection appointments over a total of 12 weeks.

Post Injection Instructions

Soft diet.Avoidance of prescription of anti-

inflammatory medications. Avoidance of Ice Application.Analgesics : Acetaminophen / Opoid

Analgesic.

Contraindications

• Allergy or sensitivity .• Active infection or malignancy in the area to

be injected.• Bleeding Disorders.

Immobilisation of Jaws

• Period : 3 – 4 weeks .• Immobilisation can be achieved by :• Arch Bars with Elastics.

Surgical Management

Capsule Tightening

1. Capsulorraphy .2. Placement of vertical

incision.3. Re inforcement of capsule.

Mechanical Obstruction

1. Le Clerc Procedure.2. Dautery Procedure.3. Bone Graft Placement.4. Pin Placement.

Le Clerc Procedure• Le Clerc and Girald in 1943. Technique :Approach :Preauricular incision.Dissection of the zygomatic arch is performed. Vertical osteotomy is done on the arch .Arch is moved inferiorly.

Dautery Procedure

• Gosserez and Dautrey 1964.• Posterior-anterior slanting osteotomy of the

eminence.• Commonly used.

• Bone Graft Placement : Mayor

• Pin Placement : Findlay

Eminectomy• Myrhaug 1951.• Removal of a portion of the articular tubercle and

eminence• Concerns :Damage to contiguous tissues.Clicking and crepitationRecurrent dislocation

Refference

• Principle of OMFS Vol – 2 – Michael Miloro.• Colour Atlas Of TMJ Surgery – Peter Quinn.• TMD Evidence based Treatment – Laskin.• Management Of TMD and Occlusion – J

Okkeson.• Maxillofacial Surgery Vol – 2 – Peter Ward

Booth.