Temporomandibular joint ankylosis

DR SAIMA GUL

1. Dr. SAIMA GUL POST-GRADUATE TRAINEE ORAL AND MAXILLOFACIAL SURGERY HAYATABAD MEDICAL COMPLEX

2. TEMPOROMANDIBULAR JOINT ANKYLOSIS

3. Temporomandibular joint is the articulation between squamous part of temporal bone and the head of mandibular condyle .

4. TMJ ARTICULATION CONSIST OF: Glenoid fossa Articular eminance Condyle External auditory meatus Zygomatic arch Sigmoid notch

5. TMJ ANKYLOSIS TMJ Ankylosis is the fusion of the Mandibular condyle with the glenoid fossa , oblitering the normal articulation and immobilizing the mandible.

6. Causes of TMJ Ankylosis INFEC INFECTION Otitis media Supurative arthritis Parotitis mastoiditis

7. Mechanism of TMJ Ankylosis

8. TMJ ANKYLOSIS Fibrous ankylosis fibro-osseous ankylosis Osseous ankylosis

9. Al-Hakim , SA Metwali 2003 CLASS I : Includes unilateral & bilatral fibrous ankylosis CLASS II : Includes unilateral or bilateral bony anlylosis CLASS III :Distance between medial pole of condyle and maxillary artery is decreased CLASS VI : Ankylosed mass appeared fused to base of skull

10. Topazian’s 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

11. DIAGNOSIS History Physical examination Radiographs

12. CLINICAL FEATURES

13. UNILATERAL ANKYLOSIS EXTRA-ORAL FEATURES : Facial asymmetry Microgenia Short posterior facial height Minimal condylar movements on palpation

14. BILATERAL ANKYLOSIS EXTRA-ORAL FEATURES: Bird-face deformity / Andy gump deformity Convex facial profile Retrognathic mandible Obtuse cervico -mental angle Marked decreased lower face height

15. INTRA-ORAL FEATURES: Midline shift towards effected side Class II malocclusion Cross-bite (unilateral/ bilateral) Limited mouth opening Neglected oral hygiene with carries & periodontal problems

16. ASSOCIATED PROBLEMS Interferes with the mastication of food and with nutrition Interference with speech Psychologic problems Prevents oral hygiene and prophylactic care Obstructive sleep apnea due to narrowing of oro -pharyngeal airway

17. RADIOGRAPHS Orthopantomogram (OPG) Reverse towne’s view ( PA-face ) Lateral cephalogram CT- scan ( axial & coronal view) Magnetic resonance imaging CT- angiogram

18. RADIOGRAPHIC FEATURES: Narrowing of joint space in fibrous ankylosis Total joint space obliteration in bony ankylosis Short ramal height Prominent antegonial notch Crowding in lower teeth Elongated coronoid process of mandible

19. ORTHOPANTOMOGRAM (OPG)

20. Lateral Cephalogram To assess Narrowing of airway Antero-posterior extension Elongation of coronoid Shortened PFH Steep mandibular plane Retrognathia Retrogenia

21. CT-scan / 3D CT-scan To assess: Relationship with the base of skull and important structures like Pterygoid plates Carotid canal Jugular foramen Foramen spinosum

22. Magnetic rasonance imaging To assess Meniscus position Fibrous ankylosis

23. Treatment

24. TEAM APPROACH Maxillofacial surgeon Orthodontist Anaesthetist Physiotherapist Nutritionist Speech therapist Psychologist Oral hygienist

25. GOALS OF SURGICAL TREATMENT Restore mouth opening Restore joint function Allow for condylar growth (children) Correct facial profile Relieve upper airway obstruction

26. 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.

27. Continue……. 6. Reconstruction of ramal height. Early post-operative aggressive physiotherapy Orthodontic treatment. Regular long term follow-up Orthognathic surgery

28. AIRWAY MANAGEMENT Blind nasal intubation Fiber-optic guided oro -tracheal intubation Elective tracheostomy

29. Surgical Approaches To TMJ Preauricular incision with modifications Post-auricular Endaural incision Coronal incision Post- ramal

30. Surgical Options Different treatment options are available High Condylectomy Gap arthroplasty Interpositional arthroplasty

31. 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.

32. 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

33. 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 .

34. 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 .

35. Interpositional materials Autogenous materials Heterogenous materials Alloplastic materials

36. Reconstruction options Autogenous grafts Alloplastic graft Distraction Osteogenesis (latest)

37. Graft materials

38. COSTOCHONDRAL GRAFT

39. Techmedica total joint prosthesis Christensen prosthesis

40. Kent- vitek prosthesis Techmedica / tmj concepts Lorenz prosthesis

41. Distraction osteogenesis

42. Distraction osteogenesis

43. CONSOLODATION PERIOD , FACIAL PROFILE

44. 3 cm of transport distraction being done

45. Latest advancement in management Navigation-aided resection of ankyloting mass Holmium-YAG laser with the help of arthroscope for fibrous ankylosis Tissue engineered TMJ reconstruction

46. Post-op treatment After 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 2 nd post-op day. Remove skin stitches on 5 th - 7 th post op day.

47. 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 .

48. continue…... 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.

49. TONGUE BLADES EXERCISE

50. FERGOSSON MOUTH GAG

51. PASSIVE MOUTH EXERCISER

52. PRE-OP MOUTH OPENING

53. INTERPOSITIONAL ARTHROPLASTY WITH ARTICULATING DISK

54. POST-OP MOUTH OPENING

55. PRE-OP MOUTH OPENING

56. INTERPOSITIONAL ARTHROPLASTY WITH TEMPORALIS FASCIA

57. POST-OP MOUTH OPENING

58. COMPLICATIONS

59. Per-op complications Difficult intubation Difficult 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 .

60. Post-op complications Extra-oral scar Infection Open bite Anaesthesia / paresthesia due to nerve damage Weakness of muscles of facial expressions Frey’s syndrome External auditory meatus stenosis Recurrence of ankylosis

61. Follow -up Asses airway Facial profile Measure mouth opening Occlusion Oral hygiene status Nutritional status Psychologic behaviour Need for orthodontic treatment/ Orthognathic surgery Any complication and its management Keep patient’s record

62. 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 3 rd 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).