tmj-ankylosis
TRANSCRIPT
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.
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