Temporomandibular joint ankylosis
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Transcript of Temporomandibular joint ankylosis
TEMPOROMANDIBULAR JOINT ANKYLOSIS
Dr. SAIMA GUL POST-GRADUATE TRAINEEORAL AND MAXILLOFACIAL SURGERYHAYATABAD MEDICAL COMPLEX
TEMPOROMANDIBULAR JOINT ANKYLOSIS
Temporomandibular joint is the articulation between squamous part of temporal bone and the head of mandibular condyle.
TMJ ARTICULATION CONSIST OF:
Glenoid fossaArticular eminanceCondyleExternal auditory meatusZygomatic archSigmoid notch
TMJ ANKYLOSIS
TMJ Ankylosis is the fusion of theMandibular condyle with the glenoid fossa , oblitering the normal articulation and immobilizing the mandible.
Causes of TMJ AnkylosisINFEC
INFECTION
Otitis mediaSupurative arthritisParotitismastoiditis
Mechanism of TMJ Ankylosis
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TMJ ANKYLOSIS
Fibrous ankylosisfibro-osseous ankylosisOsseous ankylosis
Al-Hakim , SA Metwali 2003
CLASS I: Includes unilateral & bilatral fibrous ankylosisCLASS II: Includes unilateral or bilateral bony anlylosisCLASS III :Distance between medial pole of condyle and maxillary artery is decreasedCLASS VI: Ankylosed mass appeared fused to base of skull
Topazians STAGING
Stage I : Ankylotic mass limited to condylar process
Stage II: Ankylotic mass extending to the sigmoid notch
Stage III: Ankylosis extending to coronoid process
DIAGNOSIS History
Physical examination
Radiographs
CLINICAL FEATURES
UNILATERAL ANKYLOSISEXTRA-ORAL FEATURES:
Facial asymmetry Microgenia Short posterior facial heightMinimal condylar movements on palpation
BILATERAL ANKYLOSISEXTRA-ORAL FEATURES:
Bird-face deformity / Andy gump deformityConvex facial profileRetrognathic mandibleObtuse cervico-mental angleMarked decreased lower face height
INTRA-ORAL FEATURES:
Midline shift towards effected sideClass II malocclusion Cross-bite (unilateral/ bilateral)Limited mouth openingNeglected oral hygiene with carries & periodontal problems
ASSOCIATED PROBLEMS Interferes with the mastication of food and with nutrition Interference with speech Psychologic problems Prevents oral hygiene and prophylactic careObstructive sleep apnea due to narrowing of oro-pharyngeal airway
RADIOGRAPHS
Orthopantomogram (OPG) Reverse townes view ( PA-face )Lateral cephalogram CT- scan ( axial & coronal view)Magnetic resonance imagingCT- angiogram
RADIOGRAPHIC FEATURES:
Narrowing of joint space in fibrous ankylosisTotal joint space obliteration in bony ankylosisShort ramal heightProminent antegonial notchCrowding in lower teethElongated coronoid process of mandible
ORTHOPANTOMOGRAM (OPG)
Lateral Cephalogram To assessNarrowing of airwayAntero-posterior extensionElongation of coronoidShortened PFHSteep mandibular planeRetrognathia Retrogenia
CT-scan / 3D CT-scanTo assess:Relationship with the base of skull and important structures like Pterygoid platesCarotid canalJugular foramenForamen spinosum
Magnetic rasonance imagingTo assess Meniscus positionFibrous ankylosis
Treatment
TEAM APPROACHMaxillofacial surgeonOrthodontist Anaesthetist Physiotherapist Nutritionist Speech therapistPsychologist Oral hygienist
GOALS OF SURGICAL TREATMENT
Restore mouth openingRestore joint functionAllow for condylar growth (children)Correct facial profileRelieve upper airway obstruction
Treatment protocol
Early & aggressive surgical resection of the ankylotic mass Coronoidectomy + myotomy on the affected side.If still not created enough opening, contralateral coronoidectomy is done. Lining the joint with temporalis fascia or cartilage.
Continue.
6. Reconstruction of ramal height. Early post-operative aggressive physiotherapyOrthodontic treatment.Regular long term follow-up Orthognathic surgery
AIRWAY MANAGEMENT
Blind nasal intubationFiber-optic guided oro-tracheal intubationElective tracheostomy
Surgical Approaches To TMJ
Preauricular incision with modificationsPost-auricular Endaural incision Coronal incision Post-ramal
Surgical Options
Different treatment options are availableHigh CondylectomyGap arthroplastyInterpositional arthroplasty
High Condylectomy High condylectomy is the resection of only upper part of condylar head.
It is indicated in cases of fibrous ankylosis where the articular space has not been completely eliminated.
Gap arthroplasty An osteoarthrotomy is performed to remove a slice of bone about 1.5 2 cm in width , which is known as gap arthroplasty
INDICATION:Bony ankylosis
The mouth is forced open with the help of a mouth gag to check the mouth opening -a gap of 1.5 - 2 cm is created & not interposed with any material.
Post-op, this gap is maintained by active physiotherapy to prevent re-ankylosis.
Interpositional arthroplasty
It involves the creation of gap but in addition inserting a barrier between two bony cut ends to minimize chances of re-ankylosis and to maintain the vertical height of ramus.
Interpositional materials
Autogenous materialsHeterogenous materialsAlloplastic materials
Reconstruction options
Autogenous graftsAlloplastic graft Distraction Osteogenesis (latest)
Graft materials
COSTOCHONDRAL GRAFT
Techmedica total joint prosthesisChristensen prosthesis
Kent-vitek prosthesisTechmedica /tmj conceptsLorenz prosthesis
Distraction osteogenesis
Distraction osteogenesis
CONSOLODATION PERIOD , FACIAL PROFILE
3 cm of transport distraction being done
Latest advancement in management
Navigation-aided resection of ankyloting massHolmium-YAG laser with the help of arthroscope for fibrous ankylosisTissue engineered TMJ reconstruction
Post-op treatmentAfter surgery, a pressure dressing is applied with a bandage.A drain is placed.The patient is kept on steroids + antibiotic therapy for 7 to 10 days. After 24 hours the dressing is changed .Active physiotherapy start from 2nd post-op day. Remove skin stitches on 5th- 7th post op day.
Post-op physiotherapy
Physiotherapy is as important as the surgery itself. Post- operatively for minimum for 6 months. Pressure with finger or simple finger exercises to gently force the mouth open initially with tongue blades / acrylic screw / jaw exerciser.
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A mouth gag can be used for forceful mouth opening at a later stage. During physiotherapy, medications can be given to relieve pain and enable movement. Heat application to the joint region prior to exercise permits easy movement by relieving muscle spasm.
TONGUE BLADES EXERCISE
FERGOSSON MOUTH GAG
PASSIVE MOUTH EXERCISER
PRE-OP MOUTH OPENING
INTERPOSITIONAL ARTHROPLASTY WITH ARTICULATING DISK
POST-OP MOUTH OPENING
PRE-OP MOUTH OPENING
INTERPOSITIONAL ARTHROPLASTY WITH TEMPORALIS FASCIA
POST-OP MOUTH OPENING
COMPLICATIONS
Per-op complicationsDifficult intubationDifficult tracheostomy due to smaller trachea Hemorrhage Damage to external auditory meatus.Damage to nerves (zygomatic & temporal branch of facial nerve, auriculotemporal nerve)Damage to glenoid fossa and thus perforation into middle cranial fossa. Damage to parotid gland.Damage to the teeth during opening of the jaws with mouth gag and extubation.
Post-op complicationsExtra-oral scarInfection Open biteAnaesthesia /paresthesia due to nerve damage Weakness of muscles of facial expressionsFreys syndromeExternal auditory meatus stenosisRecurrence of ankylosis
Follow -up Asses airway Facial profileMeasure mouth openingOcclusion Oral hygiene statusNutritional statusPsychologic behaviourNeed for orthodontic treatment/Orthognathic surgeryAny complication and its managementKeep patients record
References :Peter ward booth, stephen A.schendel ,jarg-erich hauseman .Maxillofacial surgery vol II second edition.Neelima anil malik.textbook of oral and maxillofacia surgery 3rd edition.Miloro M, Ghali GE, Larsen P, Waite P. Petersons principles of oral and maxillofacial surgery,volume II. Third edition.Muralee Mohan C. , B. Rajendra Prasad , Smitha Bhat & Shyam S. Bhat. reconstruction of condyle following surgicalcorrection of temporomandibular joint ankylosis: current concepts and considerations for the future. nujhs2014:4(2).Dr Neetu Dabla,1 Dr P Narayana Prasad,2 Dr Arjun Vedvyas,3 Dr Richa Aggarwal. Treatment of Facial Asymmetry and Temporomandibular Joint.Ankylosis by Distraction Osteogenesis: A Case Report.OJON2013:3(2).