TEMPOROMANDIBULAR JOINT ANKYLOSIS AND ITS MANAGEMENT

•INTRODUCTION

•CLASSIFICATION

•INCIDENCE

•AETIOLOGY

•PATHOPHYSIOLOGY

•CLINICAL FEATURES

•SEQUELAE OF TMJ ANKYLOSIS

•MANAGEMENT

Ankylosis (joint stiffness) is the pathological fusion of parts of a joint resulting in restricted movement across the joint

Ankylosis of the Temporomandibular joint, an arthrogenic disorder of the TMJ, refers to restricted mandibular movements (hypomobility) with deviation to the affected side on opening of the mouth.

INCIDENCE•Affects all age group but more in the first decade of life (0 – 10 years)

•There’s equal male and female distribution

•More common in Asian subcontinent

CLASSIFICATIONS

•Bilateral or Unilateral ankylosis

•Fibrous ankylosis or Bony ankylosis

•Intra-articular or Extra-articular ankylosis

•Complete or Partial ankylosis

•True or false ankylosis

AETIOLOGY

Trauma-At birth (with forceps)-Blow to the chin (causing haemarthrosis)-Condylar fracture

Infections and Inflammatory-Rheumatoid Arthritis-Septic arthritis-Otitis media-Mastoditis-Parotitis-Osteoarthritis

Systemic disease-Small pox-Ankylosing spondylitis-Syphilis-Typhoid fever-Scarlet fever

Others-Malignancies-Post radiology-Post surgery-Prolonged trismus

PATHOPHYSIOLOGY

TRAUMA

Extravasation of blood into the joint space

haemarthrosis

Calcificatiion and obliteration of the joint space

Intra-capsular ankylosis Extra-capsular ankylosis

CLINICAL FEATURES

•Obvious facial deformity

•Deviation of chin towards affected side

•Inability to open the jaws, absent condylar movements

on affected side

•In unilateral ankylosis, the lower jaws shifts

towards the affected side on opening of the mouth

•Flatness or fullness on affected side

•Cross bite on ipsilateral side

•Class II malocclusion on affected side

RADIOGRAPHIC FEATURES

Fusion of joint Loss of joint space Prominent antigonial notch Coronoid hyperplasia

SEQUELAE OF TMJ ANKYLOSIS

•Facial growth distortion

•Nutritional impairment

•Respiratory disorders

•Malocclusion

•Poor oral hygiene

•Multiple carious and impacted teeth

MANAGEMENT

Non surgical management

Surgical treatment

SURGICAL MANAGEMENT

Aims and Objectives of surgery

To release ankylosed mass and creation of a gap Creation of functional joint (improve patient’s oral hygiene,

nutrition and good speech)To reconstruct the joint and restore the vertical height of the ramusTo prevent recurrenceTo restore normal facial growth pattern

Procedures

1.Condylectomy

2.Gap arthroplasty

3.Interpositional arthroplasty

CONDYLECTOMY

•Fibrous ankylosis•Pre-auricular incision is made•Cut at the level of the condylar neck•The head (condyle) should be separated from the superior attachment carefully•The wound is then sutured in layers•The usual complication of this procedure is an ipsilateral deviation to the affected side. And anterior open bite if the procedure was bilaterally.

GAP ARTHROPLASTY

Extensive bony ankylosis.

The section here consists of two

horizontal osteotomy cuts

removal of bony wedges for creation of a

gap between the roof of the glenoid fossa

and the ramus of the mandible.

This gap permits mobility

The minimum gap should be 1cm to

avoid re-ankylosis

INTERPOSITIONAL ARTHROPLASTY

This is actually an improvement/modification on gap arthroplasty

Currently the surgical protocol of choice

Materials are used to interpose between the ramus of the mandible

and base of the skull to avoid re-ankylosis

The procedure involves the creation of gap, but in addition, a barrier

is inserted between the two surfaces to avoid reoccurrence and to

maintain the vertical height of the ramus

MATERIALS USED IN INTERPOSITIONAL ARTHROPLASTY

Autogenous Heterogenous Alloplastic

I. Temporalis muscles

II. Temporalis fascia

III. Fascia lata

IV. Cartiligenous graftsCostochondralMetatartsalSternoclavicularAuricular graft

V. Dermis

I. chromatised submucosa of pig’s bladder

II. lyophilized bovine cartilage

Metallic: tantalum foil and plate, stainless steel, Titanium, Gold.

 Nonmetallic: silastic, Teflon, acrylic, nylon, ceramic

Autografts, such as skin, temporalis muscle, or

fascia lata, are presently considered the material

of choice for interposition.

Advantages of these flaps in TMJ reconstruction include

close proximity to the TMJ without involving an additional surgical

site.

Complications of the surgery

Intra-OperativeHaemorrhage (damage of any superficial temporal vessels, transverse facial artery, etc)Damage to the external auditory meatusDamage to the Zygomatic and temp. branch of facial nerveDamage to the Auriculotemporal nerveDamage to the Parotid glandDamage to the teeth

Post Operativeinfection open bite

RECURRENCE OF TMJ ANKYLOSIS

•Inadequate gap created between the fragments

•Fracture of the costochondral graft

•Inadequate coverage of the glenoid fossa surface

•Inadequate post-op physiotherapy

•Higher osteogenic potential and periostal osteogenic power may be

responsible for high rate of recurrence in children