5 tmj ankylosis

Temporomandibular joint Ankylosis

1. TMJ ANKYLOSIS
PRESENTED BY:
DR. KAMINI DADSENA
New horizon Dental college & research institute Bilaspur Chhattisgarh.

2. Classification of TMJ disorder
Crainiomandibulardisorder of
organic origin
•Articular disturbances
•Disc derangements
•Condylar displacement
•Inflammatory cond.
•Arthritides
•Ankylosis
•Fractures
•Neoplasia
•Developmental abnormality
•Nonarticulardisturbance
•Neuromascularcondition
•Dental occlusal conditions
•Disturbances involving referral
of secondary symptoms
Craniomandibulardisorders of
nonorganic(functional) origin
•Myofascial pain dysfunction
syndrome
•Phantom pains
•Positive occlusal sense
•Conversion hysteria
Craniomandibulardisorders of
nonorganic origin combined
with secondary organic tissue
changes
•Articular
•Nonarticular
McNeil, Danzing, Farrar et a

3. Classification of TMJ disorder
I.Crainiomandibulardisorder of organic origin
A.Articular disturbances
1.Disc derangements
a. Disc dysfunction
b. Disc displacement
c. Disc dyscrasias
2.Condylar displacement
3.Inflammatory conditions
a. Synovitis
b. Discitis
c. Contusion
d. Rupture
4.Arthritides
a. Osteoarthritis
b. Rheumatoid arthritis
c. Polyarthritis (gout, lupus, reiters syndrome)
d. Rheumatoid variants (psoriatic, juvenile)
e. Infectious arthritis
McNeil, Danzing, Farrar et al

4. 5.Ankylosis
a.Fibous
b.Osseous
6.Fractures
7.Neoplasia
8.Developmental abnormality
a.Hyperplasia
b.Hypoplasia
c.Agenesis
B.Nonarticulardisturbance
1.Neuromascularcondition
a.Myofascitis(muscle tenderness)
b.Contracture (mechanical shortening)
c.Trismus/ spasm (reflex splinting)
d.Dyskinesia (weakness and incordination)
2.Dental occlusal conditions
a.Unstable occlusion (structure imbalance)
b.Premature posterior tooth contacts (posterior fulcruming)
c.Lack of posterior occlusal support
d.Distal thrust to mandible

5. 3.Disturbances involving referral of secondary symptoms
a.Latent myofascial tenderness
b.Active myofascial trigger points
II.Craniomandibulardisorders of nonorganic(functional) origin
A.Myofascial pain dysfunction syndrome
B.Phantom pains
C.Positive occlusal sense
D.Conversion hysteria
III.Craniomandibulardisorders of nonorganic origin combined with
secondary organic tissue changes
A.Articular
B.Nonarticular
1.Neuromuscular
2.Oral
a.Teeth
b.Periodontium
c.Soft tissue

6. Infectionof TMJ
primary source of infection:
Infection from teeth or ear
Infectious disease of childhood
Diphtheria, syphilis, gonorrhoea, ulcerative stomatitis
Penetrating wound of joint
Haematogenous spread of infection

7. Clinical sign & symptom:
Intense pain
Edemaerythema
Fluctuation
Systemic sign of infection
Fistula
Severe limitation of motion
Radiographic finding
InitialyIncrease joint space
Later joint space is narrowed
Erosion & loss of articular surface
Bone loss
Sequestration of bone
Ankylosis

8. Causative pathogen
Acute suppurativearthritis-
Staphylococcal
Streptococcal
Hemophilusinfluenzaepyarthrosis-a/c to Seymour &
summersgill
Gonorrhea-14% Trimble LD et al most common type of
infectious arthritis
Granulomatous infection

9. Management:
Aspiration and drainage
Surgical intervention –to remove necrotic bone
IV antibiotics

10. Drutzet al-J of bone joint surgery 1967
Bradly et al –Br. J of oral surgery 1971
Aspiration of pus , septrinfor 5 week
10 week later recurrence
I & D
Pus culture-actinomycesisraelii
12 week erythromycin curative

11. Trimpleet al-J maxillofacial surgery 1983
Acute staphylococcal suppurativearthritis of TMJ complicating RA
Sinus in ant. Wall of ext. auditory meatus
Initial oral antibiotics
Pain and swelling persist
Pus culture –sta. aureus
IV flucloxacillin
6 days later no improvement
Joint debridment& high condylectomy
Two drain system placed
Joint irrigated with flucloxacillinfor 4 days
Antibiotics stopped on 6
th
day
7 week later symptom returned and sinuses presented on temporal and preauricular
region
Iv flucloxacilllinstarted and andI & D performed
Iv antibiotics were cont. for 10 days followed by oral antibiotcsfor 6 weeks

13. Definitions
Ankylosis–Greek terminology meaning ‘stiff joint ‘
Hypomobility/ immobility of the joint
Obliteration of the joint space with abnormal bony morphology
Several Terms Used To Describe HypomobileJaw
Trismus
Pseudo ankylosis
True ankyloses
True ankylosisis an intracapsularcondition where there is fusion of bony surfaces
of the joint: glenoid fossa and condye

14. AnkylosisOf TMJ
1816 Howship“scrofulous inflammation of the face followed
by ankylosisof jaw”.
1883 Holmes & Hulkedescribed “ chronic otitis media leads
to sequestration of the entire mandibular condyle through the
auditory meatus .
in 1857 Esmarchsectioned the mandible via intraoral
approach without removing bone
1860 Verneuilfirst inserted guttaperchabetween the cut
surfaces.
Verneuilused temporal muscle flap as the interpositional
material .

15. Incidence
High in India
Age –2 to 63 yrs
Common before the age of 10 yrs .

16. Classification
I.Kazanzian’s
True –intraarticular
Complete
Incomplete
False –extraarticular
Bony
Fibrous

17. II.Topazian’s–true ankylosis
Type I – affects the condyle only
Type II –intermediate
Type III –entire ( condyle , coronoid , cranial base )
III.Rowe’s(according to the tissue involved )
fibrous ankylosis
Fibroosseous ankylosis
Osseous ankylosis
Cartilagenous ankylosis
Osteo cartilagenous ankylosis

18. Grading Of TMJ Ankylosis By Sawhney (1986 )
Type I –condylar head is present without much distortion
(fibrous adhesion make movement
Impossible)
Type II –bony fusion of the misshaped head and articular
surface. No involvement of sigmoid notch and
coronoid process.
Type III –bony block bridging across the ramus and
zygomayicarch &
elogationof coronoid process
Type IV –entire joint is replaced by bony mass normal
anatomy totally
destroyed

19. General classification
1.True / false ankylosis
2.Extraarticular/ intraarticularankylosis
3.Fibrous / bony ankylosis
4.Unilateral / bilateral ankylosis
5.Partial / complete ankylosis

20. Etiopathology of Ankylosis of TMJ
Trauma
Infections
•congenital
•At birth (forceps delivery )
•hemarthrosis
•condylar # - intra / extra capsular
•CSOM
•Parotitis
•tonsilitis
•Abscess around the joint
•osteomyelitis of the jaw
•actinomycosis

21. Inflammation
Systemic diseases
Other causes •Rheumatoid arthritis
•osteoarthritis
•Septic arthritis
•small pox
•scarlet fever
•Scleroderma
•beriberi
•Ankylosing spondylitis
•bifid condyle
•prolonged trismus
•prolonged immobilization
•Burns

22. Trauma –the Predominant cause of TMJ
Ankylosis
Rowe’sseries of 46 cases , 31 were the result of
trauma
Sadatrauma accounted for 58% of his 146
cases
El mofty’s39 cases , 64% were due to trauma
Sawhneyseries of 70 cases , 69 were the result of
trauma

23. Trauma
( Forceps delivery , injury involving neck of condyle )
Extravasation of blood in joint space
Clot organization
Calcification and obliteration of joint space
Ankylosis (extracapsular )
Immobilization (< 4 weeks )
Meniscus undergoes progressive destruction
Flattening of the glenoid fossa & thickening of the condylar head
Ankylosis (Intraarticular )

24. Factors Contributing To Ankylosis
1.Age of patient
2.Site and type of #
3.Length of immobilization
4.Damage to the meniscus

25. Diagnosis
restricted oral opening or nil oral opening
difficulty in mastication
protrusive movements absent on involved side
pain usually absent
Unilateral ankylosis
obvious facial asymmetry
deviation of chin on affected side
roundness & fullness of face
flatness and elongation on unaffected side
well defined antegonial notch
post cross bite
condylar movements absent on effected side

26. Bilateral ankylosis
Inability to open the mouth
Mandible symmetrical but micrognathic
Bird face deformity
Antigonialnotch well defined bilaterally
Upper incisors protrusive with ant open bite
Multiple carious teeth with bad PDL health
Severe malocclusion , crowding .
Multiple Impacted teeth may be found on radiograph

27. Radiographic features

28. By Sahwneyacc. To the type of ankylosis ;
Type I & II –a discrete section of condyle is excised with a gap of 3 – 5 mm is
made, fibrous adhesion is removed
if meniscus is intact no interpositional material is required
if meniscus is damaged / absent interpositionalmaterial is
inserted
Type III --extraarticularbony bridge extending from zygomatic arch to the
ramus is removed
Type IV – new joint is fashioned to restore function
in children(12-13) IMF for 10 –14 days followed by early
mobilization and physiotherapy
Acc. To Ware & Munroeet al. costochondral graft should be used.
Surgery

29. Kaban’sprotocol for management of TMJ ankylosis
1.Early surgical intervention
2.Aggressive resection (gap = 1-1.5 cm) specially med. Aspect of the ramus.
3.Ipsilateral coronoidectomy& temporalis myotomy, the interincisalopening
should be = 35mm
4.Contralateral coronoidectomy& temporalis myotomynecessary if max.
incisalopening < 35mm
5.Lining of glenoid fossa with temporalis fascia.
6.Reconstruction of the ramus with a costochondral graft.
7.Early mobilization and aggressive physiotherapy for six months
8.Regular long term follow up.
9.To carry out cosmetic surgery when the growth of the patient is completed.

30. •Creata gap to mobilize the joint
•To improve patient’s nutrition
•To improve patient’s oral hygiene
•To carry out necessary dental treatment
•To reconstruct the joint and restore the vertical height of the ramus
•To prevent recurrence
•To improve esthetics and rehablitatethe patient
Aims and objectives of surgery

31. Surgical approaches to TMJ
1.Submandibular (Risdon’s)
2.Postramal (Hind’s)
3.Postauricular
4.Endural

32. 5. Preauricular
Dingman’s
Blair’s
Thoma’s
Popowich’s modification of Al –kayat & Bramley’s
6. Hemicoronal & bicoronal (Obwegeser’s)

33. AdvantagesofPopowichmodification of Al –Kayat & Bramley’sapproach
1.Reduction in incidence of facial nerve palsy
2.Provision for donor site for temporalis fascia
3.Dissection through avascular zone
4.Improved visibility (facial planes)
5.Good cosmetic result
6.Avoidence of auriculotemporal nerve anaesthesia
7.Reduction in total operating time

34. Modification of basic preauricularincision
All these modification of basic preauricularincisions were
made to have better access and visibility, and wider
exposure and to prevent injury to the auriculotemporal
nerve and the branches of the facial nerve.
Blair and Ivy (1936) used an inverted hockey stick incision
over the zygomatic arch, which gave easy access and
better visibility and also facilitated exposure of the arch
along with condylar area.
Thoma(1958)recommended an angulated vertical
incision which is carried out across zygomatic arch in the
fold, directly in front of the ear, extending down slightly
above the ear lobe, to avoid the main trunk of facial
nerve.

35. Al-kayatand Bramley(1979)described a modified preauricular approach to
TMJ and zygomatic arch considering the main branches of the vessels and
nerves in the viscinity.
According to Al-kayatand bramley,facial nerve divides at a point between
1.5-2.8cms below the lowest concavity of the bony external auditory canal. The
temporal nerve branches lie within a dense fusion of periosteum, temporal
fascia and superficial fascia at the level of zygomatic arch. Al Kayatand
Bramleyfound that protection of the nerve can be achieved by making an
incision through the temporal fascia and periosteum down to the arch, not
more than 0.8cms in front of the anterior border of the external auditory canal.
Popowichand Crane (1982)further modified basic Al-Kayatand Bramley’s
incision. A large incision shaped like a question mark was made in the temporal
area and extended in the preauricular area. This approach gives excellent
visibility with a safety to the zygomatic arch and joint. The skin incision is a
question mark shaped and begins about a pinna’s length away from the ear,
anteroposteriorlyjust within the hair line, curves backward and downward well
posterior to the main branches of the temporal vessels, till it meets the upper
attachment of the ear. The rest of the incision is same as the routine
preauricularincison.
The temporal incision is carried through the skin, superficial fascia to the level of
temporal fascia.
The facial nerve branches run in the superficial fascia and so it is important that
the full length of this fascia is reflected with the skin flap.
Blunt dissection is carried out till about 2cms above the zygomatic arch, where
the temporalis fascia splits.
Starting at the root of the zygomatic arch, an incision running at 45 degrees
upward and forward is made through the superficial layer of the temporalis

36. fascia. The zygomatic arch is exposed after reflecting periosteum, lateral
layer of temporal fascia and superficial fascia as one layer.
Downward dissection will expose the capsule and then the dissection is
carried out as usual.
Advantages
Reduction in incidence of facial nerve palsy.
Provision of donor site for temporalis fascia.
Decreased haemorrhage(dissection through avascular zone).
Improved visibility and identification of fascial planes).
Reduction in post operative edema and discomfort.
Potential complication of muscle herniation and fibrosis avoided.
Good cosmetic results.
Avoidance damage to auriculotemporalnerve.
Reduction in total operating time.

37. Management:
Infancy
•Unusual
•Cause:
•Agenesis
•Birth trauma
•Infection
•Aim:
•Restore
movement and
function
•Reconstruction
later
Childhood
•Cause:
•Trauma
•Infection
•Aim:
•Restoring
function and
movement
•Bony
replacement
with CCG
•Correction of
occlusal and
cosmetic
deformity
•Early teen-DO
•Late teen-
bimaxillay
surgery
Adult
•Cause:
•Trauma
•Aim:
•Restoration of
satisfactory
movement

38. Child adult

39. 1.Condylectomy
2.Gap arthroplasty
3.Interpositionalarthroplasty
Surgical techniques

40. Condylectomy;
Indications
Fibrous ankylosis
demarcation between the roof of the glenoid fossa and
head of the condyle is seen.

41. Gap arthroplasty
Indications
extensive bony ankylosis
a broad thick area of bone deposition obliterating the entire
joint
identification of the previous joint structure impossible

42. Gap Arthroplasty

43. Interpositionalarthroplasty;
To minimize the risk of recurrence and to maintain the
vertical height of the ramus.

44. Replacement of the mandibular condyle and ramus
1.Reconstruction of the glenoid fossa
2.Replacement of the meniscus
Three types
1.
Autogenous
Temporal fascia
Temporal fascia & pericranium
Fascia lata
Dermal graft
Auricular cartilage
Costochondralcartilage & bone composites
Interpositional Materials

45. 2. Allogenic
freeze dried dura
cryopreserved cartilage
allogenic bone
3. Alloplastic
metals--stainless steel alloy
cobalt chromium alloy titanium
ceramics–aluminiumoxide
hydroxyapatite compact
polymers--dimethylsiloxane
composites–teflon
silastic(dowcorning comp midland Michigan)
proplast
goretex
Polyethylene acrylic
vitek, Houston ,texas

46. Sawhneyoffered lucid classification
of ankylosis:
Type I-flattening or deformity of condyle with little joint
space. Min. bony fusion and extensive fibrous adhesion
Type II-bony fusion in outer edge of articular surface but
no fusion in deeper area
Type III-bony bridge between ramus of mandible and
zygomatic arch.
Type IV-entire joint is replaced by bony mass

47. Ankylosisin children:
Incision- preauricularincision
preauricular+ Risdon- grafting
Type I & II discrete section of condyle with
reciprocating saw or power instrument
Gap 3-5 mm has been made , fibrous adhesion
removed
If disc is intact, no interpositional material req.
Joint is manipulated through wide range of
movement.
Wound is irrigated and closed in layers

48. If the meniscus is damaged or absent and glenoid fossa is
altered After condylar osteotomy inter position material
must be inserted
Type III –removal of bony brigde.
Type IV-Total new joint must be fashioned to restore
function.
Horizontal cuts are made below the mass of bone(area
aprroxnear condyle) another cut at the level of inferior
border of zygoma .
It reduce the vertical ht of ramus, require restoration with
CCG or other alloplast or silastic.
Early joint mobility and physiotherapy

49. Adult ankylosis:
Massive ankyloses- gap arthroplasty and making false joint
Interpositionalmaterial must be use silasticor alloplast, temporal
muscle pedicle flap, fascia lata can be used.
it is preferable to used Glenoid fossa implant bcz it can firmly
attached and will cover entire fossa.
Where vertical hightis reduced, rib graft or prosthesis is preferred
to large block of silastic.
In some cases total joint prosthesis is indicated.
Obwegesercoronal approach is used for that.
Simultaneous coronoidectomy.

50. CostochondralRib Grafts in
mandibular Reconstruction:
Poswillowas the first surgeon to truly establish the
physiologic compatibility of costochondralgrafting
for the TMJ
Other donor site:
1.Sternoclavicular
2.metacarpal joints
Costochondralgraft is the autogenous
reconstruction material of choice for TMJ
arthroplasty in the pediatricpopulation.
RuiFernandeset al Atlas Oral Maxillofacial Surg Clin N Am 14 (2006) 179– 183

51. Reason
1.native size and dimensions
2.hyaline cartilaginous cap (as opposed to
fibrocartilage) can withstand the biomechanical
stresses of the TMJ
3.act as a new growth center
Indication
1.adult patients who have failed multiple alloplastic TMJ
implants
2.Most patients who require a costochondral rib graft for
TMJ arthroplasty are growing patients who have
ankylosisof the joint (intracapsular)
3.suffer from a neoplasm of the condylar head that
requires a condylectomyand immediate
reconstruction

52. Goals of reconstruction :
1.to re-establish the vertical height of the lower
face (ramus),
2.re-establishthe premorbid occlusion,
3.allow for a dynamic grow of the new condylar
head as the cartilaginous cap of rib continues
to grow.

53. A costochondralrib graft with a cartilaginous cap secured to the
native mandible can be expected to grow spontaneously in a
growing patient.
The rate of reankylosisafter costochondralrib grafting is most
common in adult patients
One of the most unpredictable factors regarding costochondral
bone grafting is the degree of growth. lack of growth and potential
reankylosisare possible, overgrowth of the costochondralrib graft is
the most common scenario after TMJ arthroplasty in growing
patients.

55. The incision is made with a #15 blade, and dissection is then
continued with electrocautery. The muscles are dissected and the
rib is exposed.
The periosteum is reflected from lateral toward the medial aspect
of the dissection.
Care should be taken so as not to injure the vascular bundle when
reflecting the periosteum on the inferior aspect of the rib
In cases of segmental mandibular resections that do not involve the
condyle region in infant patients, a segment of the rib may be used
to graft the continuity defect.
The periosteum is reflected superiorly and inferiorly, and the inner
aspect is reflected with the aid of a Doyen (pigtail) retractor.
Once the appropriate length is dissected, the medial cut is done
followed by the posterior cut with the aid of a guillotine rib cutter.

57. In instances in which a cartilage cap is needed, the
dissection is extended to the costochondraljunction, with
care taken to leave the overlying
periosteum/perichondrium in the area intact.
This maneuveraids in the retention of the cartilage cap to
the rib. Approximately 2 to 5 mm ofncartilageis maintained
on the graft, and the medial incision is completed with the
use of a blade
The remainder of the harvesting is the same as prev.
manner
Once the harvest is completed, the anesthesiologistis
asked to give a positive pressure breath and the presence
of air leaks is checked.
If one is detected, a small catheter is inserted and a purse
string suture is placed around the opening.
With the anesthesiologistgiving a positive pressure breath,
the catheter is removed while the suture is tied. In the event
that this maneuveris not successful, it may be repeated

59. The incision is closed in layers, taking care to reapproximate
the periosteum followed by the muscles.
The dermis is closed and a running subcuticular closure is
used to close the skin. The incision is covered with steristrips.
The harvested costochondralgraft is transferred to the head
and neck, where the recipient site has been prepared. The
distal mandible is well exposed, as is the glenoid fossa.
The rib graft is then placed in the most ideal position and
secured to native mandible with the aid of titanium plates or
wire fixation or both
Titanium plates can be cut into individual ‘‘washers’’ along
with bicorticalscrews to secure the rib to the native
mandible.
This technique serves to decrease the likelihood of graft
fracture caused by dissipation of stress forces along the graft.
Particular care also must be taken at this time not to disrupt
the cartilage cap.

60. Once the graft is secured, the patient is taken out of
intermaxillaryfixation and the occlusion and rotational
and translational movements of the mandible are
checked passively.
When these movements are found to be satisfactory to
the surgeon, the area is irrigated with saline-containing
antibiotic and the neck is closed in a standard fashion.
The patient may be placed once again in intermaxillary
fixation before awakening.
The fixation may be maintained for a period of 2 weeks.
Upon arrival to the postanesthesia care unit, a chest film is
obtained to rule out the presence of a pneumothorax

64. Complications
loss of the cartilage cap
pleural tears.
In cases in which the cartilage cap is separated from
the rib, the authors prefer to secure the cap to the
graft using nonresorbablesutures
Pleural tears can be managed as stated in the
technique section.
Cosmetic defects of the chest wall,
areola retraction

65. Postoperative care:
Monitoring of airway and bleeding
Early joint mobilization
Physical therapy should be initiated as soon as
tolerated by pt
Ice pack followed by hot pack
Finger exercise, gradually larger bundle of
tongue depressor as wedge.

66. Complications During TMJ Ankylosis
Surgery
1.Haemorrhage
2.Damage to external auditory meatus
3.Damage to zygomatic and tamporalbranches of facial nerve
4.Damage to glenoid fossa entry into the middle cranial fossa
5.Damage to auriculotemporalnerve
6.Damage to parotid gland
During postoperative follow up
1.Infection
2.Open bite
3.Implant failures
4.Recurrence of TMJ ankylosis

67. Frey syndrome:
1
st
described by frey.
It is localisedgustatory sweating in the area supplied by
auriculotemporalnerve.
Cause:
Congenital or acquired
Surgery of parotid gland, TMJ , parotid abscess, facial wound.
Clinical feature:
1.Pain in area supplied by ATN
2.Gustatory sweating
3.Erythema& flushing
4.Positive iodine starch test

69. Treatment:
1.Antiperspirants
2.Anticholinergicprepn: glycopyrolate
3.Botulinumtoxin A inj.
4.Radiation therapy: 50 Gy
5.Surgical:
i.Skin excision: for localise & small area
ii.ATN section: not permanent
iii.Tympanic neurectomy: safe procedure

70. Conclusion:
Trauma is most common cause of ankylosis
Intacapsular
Paediatric patients
Unilateral-asymmetry
Bilateral-dramatic hyplasiaof mandible
Role of condyle
Articulating unit
Growth centre
Goal of treatment
Restoration of Function
Aesthetic

71. reference
Surgery of tmjdavidkeith
Operative omfsby john Langdon
RuiFernandeset al Atlas Oral Maxillofacial Surg Clin N
Am 14 (2006) 179–183

72. Thank you