Classification of Diseases of TMJ and TMJ ankylosis in detail

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1. Diseases of TMJ (Temporomandibular Joint) & TMJ Ankylosis Presented By – Sanket Agrawal (Intern) Guided By – Dr. Tushar Dubey Sir Dr. Karan Jadhav Sir

2. Contents Introduction to TMJ Disorders Some special features of TMJ Classification of TMJ Disorders Causes of TMJ Disorders Diagnosis and treatment of TMJ Disorders TMJ Ankylosis : incidence, etiology, clinical feature & management Various surgical approaches to TMJ

3. Temporomandibular Joint (TMJ) disorder refers to a cluster of conditions characterized by pain in the TMJ or its surrounding tissues, functional limitations of the mandible or clicking in the TMJ during motion Introduction to diseases of TMJ

4. Some special features of TMJ The TMJ is thus classified as a complex, multiaxial , synovial, bicondylar and ginglymodiarthrodial type of joint. It is highly specialized unique joint and has got many distinctive characteristics: Articular surfaces of TMJ are not covered by a hyaline cartilage, but by an avascular fibrocartilage (This is attributed to the membranous ossification by which the mandible, temporal bone and clavicle are formed. Clavicular end of sternoclavicular joint is also covered by avascular fibrocartilage).

5. The right and left articulations are connected by the mandible, the movements are coupled. Th e individual movement of one articulation directly affects the other. Mandible is stabilized by three functionally linked articulations—the dentition and the two TMJs. Any discrepancy of the dentition will affect the movements of the TMJ.

6. The function of this unique joint is also dependent on delicate neuromuscular balance. The TMJ is the only joint to have a rigid end point of closure, produced as a consequence of teeth contacting. The TMJ is in close proximity to the upper part of the cervical spine. Functionally, the cervical spine, the TMJ and occlusion of teeth are interrelated. Abnormality of any of these components can alter the function.

7. Classification of TMJ Disorders Classification based on the type of the disorder A) Developmental Disturbances of TMJ : Aplasia of mandibular condyle Hypoplasia of mandibular condyle Hyperplasia of mandibular condyle B) Traumatic Disturbances of TMJ :

8. Ankylosis Injuries of articular Disc Fracture of condyle Luxation or subluxation C) Inflammatory disturbances of TMJ : Arthritis Rheumatoid Arthritis Osteoarthritis D) Neoplasms

9. Benign • Osteoma • Chondorma • Osteochondroma • Fibromyxoma • Synovioma Malignant • Osteosarcoma • Chondrosarcoma • Synovial sarcoma • Malignant Lymphoma

10. E) Neuropathic Charcot Joint Ritter Sympathetic Dystrophy F) Internal Derangement Disc Displacement Disc fracture

11. Causes of TMJ Disorders It may result of casualties, the wear caused by age, and behavioral factors. Casualties: Can be severely injured in the TMJ lead to disorders, for example, it can result in a severe blow on the jaw to break bones or damaged disk, could destroy the smooth movement of the joint, causing pain or bad occlusion.

12. Wear cauśed by age:wear TMJ, because of age, cause disturbances in the joint, for example sore joint. It can also for arthritis jaw that caused also injured. Bebavioral factors: It can cause behaviors or certain situations, in some cases, disorders of the temoromandibular joint, for example, continuous chewing gum nay lead some people to unrest in the TMJ.

13. Diagnosis The diagnosis of TMJ Disorders may be difficult because the exact cause of these disorders and their symptoms are not known There is no specific test to diagnose TMJ Disorders In most cases symptoms are considered as key role in diagnosis of the diseases

14. Diagnosis Dental imaging and radiography is not always useful in all cases, we need to have another X-Ray methods such as detailed MRI and CT scan imaging Physical examination to feel the hinged jaw and the muscles of mastication includes looking for the place of pain and to listen to the voices of cracking during movement of joint and search for the existence of limited movement

15. Treatment Rest the jaw, patient needs to avoid chewing gum, and refrain from opening their mouths at large You can warm compress and ice packs to loosen the muscles and give cold packs treatments To TMJ after a direct hot better than warm treatment packs

16. Treatment The doctor may prescribe drugs to treat inflammation or relaxing muscles or pain control and if the pain is mild you can use regular painkillers sold without a prescription Toxin injection (Botox) in the muscles of the Jaw may be used to relieve the TMJ pain disorders.

17. Treatment If the pain is caused by screwing on the teeth bacause of psychological distress, the relaxation methods designed to ease the distress can help to relieve pain caused by TMJ disorder The doctor has recommended the development of an oral treatment device, a splint or plate bitten – a protective plastic based on the upper or lower teeth. The splint can help to ease the tension on the teeth, which relieves muscle tension, it should be the use of oral splint for a short time

18. Surgical treatment Surgical treatment remains controversial, which is often reversible and should be avoided as much as possible, where it has not been so far extended clinical trials to study the safety of surgical treatments and their success in the treatment of TMJ disorder.

19. Surgical Approaches to TMJ

20. TMJ Ankylosis 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.

21. Incidence Affects in all age group but more common in first decade of life (0-10 years of age) Equal M=F gender distribution More common in Asian Subcontinent

22. Classifications Unilateral or Bilateral Ankylosis Fibrous or Bonu ankylosis Intra-articular or Extra-articular Ankylosis Complete or Partial Ankylosis True or False ankylosis

23. SAWHNEY’S Grading of TMJ Ankylosis

24. Etiology Trauma : At birth Blow to the chin Condylar Fractures Systemic Diseases : Small Pox Ankylosing spondylitis Syphilis Typhoid fever Scarlet fever

25. Infections and Inflammatory : rheumatoid arthritis Septic arthritis Otitis media Mastoditis Parotitis Osteoarthritis Others : malignancies Post radiology Post surgery Prolonged trismus Burns

26. Clinical Features Unilateral Ankylosis Facial asymmetry Affected side appears normal Opposite side appears flat Chin deviated to ankylosed side Deep antegonial notch on ankylosed side Reduced condylar movements on affected side Class Il malocclusion on affected side. Decreased mouth opening Posterior cross bite. Poor oral hygiene

27. Bilateral Ankylosis Bird face Trismus Class II malocclusion
Deep antegonial notch
Poor oral hygiene
Crowding of teeth
Protrusion of upper anterior teeth
Anterior open bite
No condylar movements palpable

28. Radiographic Features Fusion of joint Loss of joint space
Prominent antigonial notch
Coronoid hyperplasia

29. Sequelae of TMJ Ankylosis Facial growth distortion
Nutritional impairment
Respiratory disorders
Malocclusion
Poor oral hygiene
Multiple carious and impacted teeth

30. Management Surgical 1) Condylectomy 2) Gap Arthroplasty 3) Interpositional Arthroplasty

31. 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

32. The usual complication of this procedure is an ipsilateral deviation to the affected side. And anterior open bite if the procedure was bilaterally.

33. 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 1 cm to avoid re- ankylosis

34. Interpositional Arthroplasty This is actually an improvement/modification of 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

35. Interpositional Materials Used :-

36. Esmarch’s Procedure for Ankylosis

37. This is of historical significance only. Esmarch made a small incision posterior to the angle of the mandible and dissected the masseter and medial pterygoid muscles off the bone. A 2.5 cm wide wedge of bone, at the angle of the mandible with apex at upper border and base at the posteroinferior border, was removed. The muscles were then sutured back.

38. Artificial Replacement of the Joint Prefabricated condylar prosthesis made of steel , vitallium or titanium , proplast , teflon , etc. have been also used extensively. Fossa liners along with especially constructed TMJ prosthesis reconstruct the entire joint. These are commercially available or custom fabricated

39. Kabans protocol Aggressive total excision of the ankylotic segment in condylar region. Coronoidectomy on affected side to avoid temporalis muscle restriction.
Lining with temporalis muscle or fascia or disc.
If step 1,2,3 don’t create enough opening, coronoidectomy of opposite side is done.
Reconstruction of ramus with costochondral junction
Creation of open bite to permit settling of graft for 3-6 months.
Aggressive physiotherapy.

40. Causes of Recurrence of Ankylosis Improper or inadequate surgical resection.
Fracture of costochondral graft.
Improper graft fixation.
Inadequate physiotherapy.
Increased osteogenic potential of the resected segments.

41. Surgical Approaches to the TMJ P1 and P2 : Preauricular Approaches PA : Postauricular Approach I : Inverted Hockey Stick Approach E : Endaural Approach R : Retromandibular Approach

42. Al- kayat and Bramley Incision In some cases, to maximize the exposure to the TMJ, preauricular incision is modified to a question mark pattern presented by Al- Kayat and Bramley Al- kayat and Bramley Incision to expose the TMJ for Condylectomy

43. References 1: Textbook of Oral and Maxillofacial Surgery – Neelima Anil Malik 2: Textbook of Oral surgery – S M Balaji

44. Thank You !!!