TMJ ANKY AR.pptx

Temporomandibular joint

1. TMJ ANKYLOSIS DR ANKITA RAJ (PROFESSOR) DEPT OF ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS HISTORY ETIOPATHOGENESIS OSA CLASSIFICATION CLINICAL FEATURES RADIOLOGICAL FEATURES AIMS AND OBJECTIVES INTUBATIONS SURGICAL ANATOMY PROCEDURES SOFT TISSUE INTERPOSITIONAL MATERIALS HARD TISSUE RCU RECONSTRUCTION TOTAL TMJR SECONDARY DEFORMITIES

3. INTRODUCTION

4. Humphrey in 1984 first performed condylectomy Esmarch was said to be the first surgeon to perform an osteotomy for treating mandibular ankylosis in 1851. Abbe introduced the GA technique in 1880. Risdon in 1934 used interpositional material. Gillies first described TMJ reconstruction with costochondral graft HISTORY

5. Pickeril (1942) : used cartilagenous graft in TM Joint ankylosis Papageorge and Apostolids (1999) : published report on simultaneous mandibular distraction and gap arthroplasty in T.M.J. Ankylosis. Yonehara (2000) : reported gradual distraction helped to recreate harminous soft tissue and bony elongation of hypoplastic mandible. HISTORY

6. 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 ) Disc undergoes progressive destruction Flattening of the glenoid fossa & thickening of the condylar head Ankylosis (Intraarticular )

7. Dual effect of mouth opening on new bone formation in recent condylar trauma

8. Importance of OSA • Retruded mandible causing narrowing of PAS • Mechanical obstruction to respiration: Apnoea Hypapnoea episodes, reduction in the mean oxygen saturation levels and secondary cardiac and respiratory problems • Ankylosis release without advancement of mandible: worsening of already compromised airway • Mouth opening exercises can lead to upper airway collapse

9. CLASSIFICATION

10. Juxta-articular ankylosis

11. Topazian’s – true ankylosis Type I– Affects the condyle only Type II – Intermediate Type III – Entire ( condyle , coronoid , cranial base )

12. Rowe’s (according to the tissue involved )

13. Shanghai Ninth People’s hospital classification of TMJ ankylosis based on Coronal CT

14. Yan and colleagues (2014) Based on its development, ankylosis can be classifed into three phases: • Fibrous-chondral phase demonstrating fibrous tissue and chondrocytes occupied the joint gap • Chondral-calcified cartilage phase manifesting abundant chondrocytes, cartilage matrix, and neo-formative endochondral ossification in the joint space • Bone-cartilage phase showing compacted bone bridge in the lateral joint gap and cartilage in the medial joint gap

15. Restricted oral opening Difficulty in mastication Protrusive movements absent on involved side Pain usually absent Diagnosis

16. RADIOLOGICAL FEATURES Ankylosed Mass OPG Elongated coronoid process

17. ( Yan et al. Head & Face Medicine 2014, Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis) Yan et al. -enlarged condyle, thickened temporal bone, excessive bone formation, and a radiolucent zone in the bony fusion area

18. CT SCANS

19. Preoperative Assessment Investigations Detailed history, complete clinical examination, professional photographs, for documenting the: Age of onset of ankylosis Type, duration, and extent of ankylosis Type of joint injury or infection (d) Maximal interincisal opening (e) Dental characteristics and occlusion (f) Type of facial deformity (g) Previous surgery

20. 2.Routine hemogram and pre-op major investigations 3. Radiological examinations for evaluation of extent of ankylotic mass, discrepancy of jaws, and treatment planning (a) Orthopantomogram:

21. ( d) Facial CT scan:

22. The standard components of the polysomnogram include the electroencephalogram (EEG), electro-oculogram (EOG), electromyogram (EMG) and electrocardiogram (ECG, leadV2)

23. 3D stereolithographic models printed, with the help of CT scan, may be used in treatment planning .

24. TREATMENT AIMS AND OBJECTIVES

25. Surgical technique selection depending on following: Age of onset of ankylosis Extend of ankylosis Unilateral/bilateral involvement Associated facial deformity

26. Protocol for release, Interposition & RCU reconstruction Kaban’s Protocol for Management of Temporomandibular Joint Ankylosis (1990) I. Aggressive resection of the ankylotic segment II. Ipsilateral coronoidectomy III. Contralateral coronoidectomy when necessary IV. Lining the joint with temporalis fascia or cartilage V. Reconstruction of the ramus with a costochondral graft VI. Rigid fixation of the graft VII. Early mobilization and aggressive physiotherapy

27. II. Kaban’s modified protocol for management of Tmj Ankylosis in children (2009) a) Aggressive excision of fibrous and/or bony mass b) Coronoidectomy on affected side c) Coronoidectomy on opposite side if steps 1 and 2 do not result in MIO of 35 mm or to point of dislocation of opposite side d) Lining of joint with temporalis fascia or the native disc, if it can be salvaged e) Reconstruction of RCU with either DO or CCG and rigid fixation f) Early mobilization of jaw; if DO used to reconstruct RCU, mobilize day of surgery; if CCG used, early mobilization with minimal intermaxillary fixation (not > 10 days) g) Aggressive physiotherapy ( Kaban , Bouchard, and Troulis . Management of Paediatric TMJ Ankylosis. J Oral Maxillofac Surg 2009.)

28. CONDYLECTOMY

29. A2 PREOP A3 LATERAL ARTHROPLASTY A2 POST OP

30. They have stated that the intermittent compressive forces of the joint may act as a negative influence on the growth and also explained the fat tissues are maintained within the joint space itself

31. RCU RECONSTRUCTION IN TMJ ANKYLOSIS

32. After release of ankylosis Are we reconstructing RCU ? AHI:69.7

33. Goals Improvement of mandibular form and function B/l cases: Restoration of height of ramus Prevention of further morbidity U/l cases: Decrease lateral deviation and improve stability Normalization of occlusion

34. Materials for reconstruction Autogenous grafts : Derived from vicinity - Ankylotic Mass - Coronoid Process - Posterior Border Ramus Osteotomy VRO LRO Derived from distant site - Costochondral Graft - Sternoclavicular Graft - Iliac crest - Fibula Graft Metatarsal Graft Transport Distraction Alloplastic grafts : - Hydroxyapatite collagen block - Total TMJ Replacement System Lateral Arthroplasty

35. Materials for reconstruction Autogenous grafts : Derived from vicinity - Ankylotic Mass - Coronoid Process - Posterior Border Ramus Osteotomy VRO LRO

36. Materials for reconstruction ANKYLOTIC MASS

37. Ankylotic Mass 3 Adults no reankylosis at 12 months F/U R. Gunaseelan: IJOMS 1997 H/p - Bony trabeculae having marrow elements, focal fibrosis, collagenization - normal cartilage calcification Nanda Kishore Sahoo, J Craniofac Surg 2012

38. Resected ankylotic mass Post-op OPG with graft Recontoured graft fixed with 2, 4mm screws

39. Surgical considerations in rcu reconstruction Final position of neocondyle in glenoid fossa Determined by position of ramus Occlusion Length of graft trimmed accdg to original height of ramus Fixation of graft

40. MERITS No donor site morbidity Recycling of bony ankylotic mass Dense bone with smooth cortical surface DEMERITS Not always possible to resect ankylotic mass in bulk without risking internal maxillary artery Vishal Bansal, BJOMS 2016

41. Materials for reconstruction CORONOID PROCESS

42. Coronoid Process Pedicled on Temporalis Muscle Temporalis stripped off except anterior portion attached to tip of coronoid Yiming Liu, OOOO 2010 Less Resorption Less decrease in ramus height Less deviation in mouth opening

43. Coronoid Process – Potential for continued growth Boon or bane? Effect on mouth opening?

44. MERITS Harvested safely & easily Size, shape, & thickness suitable for reshaping DEMERITS Nonpedicled – chances of resorption If ankylosed segment also involves coronoid & is removed in pieces, then cannot be used A. Khadka, J. Hu: Int. J. Oral Maxillofac. Surg. 2012

45. Materials for reconstruction POSTERIOR BORDER RAMUS OSTEOTOMY

46. Posterior border Ramus Osteotomy First described by Markowitz in 1989 Traditional approach – gap or interpositional arthroplasty Reconstruction with non pedicled grafts Resorption of graft Decrease in height of ramus Deviation on mouth opening Facial asymmetry Y. LIU,Int . J. Oral Maxillofac. Surg. 2011

47. Materials for reconstruction VERTICAL RAMUS OSTEOTOMY

48. Vertical Ramus Osteotomy Osteotomy of posterior border for condylar hypertrophy Medial pterygoid attachment prevents resorption Y. LIU,Int . J. Oral Maxillofac. Surg. 2011

49. Total VRO cut Sliding Recon Contouring & fixation

50. Materials for reconstruction L RAMUS OSTEOTOMY

51. L-shaped Ramus Osteotomy Modification of VRO Osteotomy is performed 1.0 cm above mandibular angle Y. LIU,Int . J. Oral Maxillofac. Surg. 2011

52. L- SHAPED RAMUS OSTEOTOMY

53. Materials for reconstruction VRO V/S LRO

54. VRO vs Lro Height of ramus Difference in indication: antegonial notch

55. MERITS Avoids resorption, infection, donor-site complications Adequate size & shape for new condyle with same histologic characteristics less decrease in height of ramus, less deviation Resolves problems of secondary mandibular asymmetry due to Re- restoration of growth spurts (moss functional matrix theory) DEMERITS Cannot be used if width & height of ramus is inadequate Lack of inherent growth Extra incision Y. LIU,Int . J. Oral Maxillofac. Surg. 2011

56. Materials for reconstruction Autogenous grafts : Derived from vicinity Derived from distant site - Costochondral Graft - Sternoclavicular Graft - Iliac crest - Fibula Graft - Metatarsal Graft

57. Materials for reconstruction COSTOCHONDRAL GRAFT

58. costochondral Graft Popularized by Poswillo , 1987 Replaces vertical bony portion of ramus & cartilage of condyle Variables: Which ribs How much cartilagenous cap? How to fix? ? Post op IMF Resorption Vs Hypertrophy N. R. Saeed . IJOMS. 2003

59. Harvesting of CCG A) LENGTH OF GRAFT & CARTILAGENOUS CAP: Vishal Bansal, BJOMS 2016 Cartilaginous cap - 2-4mm in length Graft taken from - 4 th or 6 th rib H. Sharma et al, JMOS 2015 Cartilaginous cap - 4–5 mm. Graft taken from - 5th or 6th rib . Samman , IJOMS 1995 & Link JO, JOMS1993 5 mm cap – linear overgrowth of CCG unit

60. B ) HOW TO FIX: - Extraorally with screws/ miniplates - Extraorally with shaving of ramus - Intraorally C) POST OP INTER-MAXILLARY FIXATION : - No clinical difference in outcome b/w early release v/s IMF Ahmed M.M. Medra , BJOMS 2004,

61. Meticulous dissection of periosteum & perichondrium Retaining intact periosteum & perichondrium at CC junction Harvesting alternate ribs - Prevents pain & pleural tear Sectioning chondral part before osseous part - Reduces fracture costochondral junction 3-4 mm of chondral portion -helps to avoid overgrowth A. Khadka , J. Hu: Int. J. Oral Maxillofac. Surg. 2012 To maximize chance of survival of graft :

62. D) RESORPTION OR HYPERTROPHY: Jean Salash, JOMS 2015 Out of 72 cases Excessive growth on treated side - 54% Growth equal to that on opposite side occurred - 38% Peltomaki, JOMS 2002 Inability of CCG to adapt to growth velocity of new environment

63. Biological compatibility, workability & functional adaptability Growth potential Morbidity of donor site Un predictable growth pattern Contraindication - Recurrent Ankylosis MERITS DEMERITS

64. Materials for reconstruction STERNOCLAVICULAR JOINT

65. Sternoclavicular Graft Sternoclavicular joint & TMJ are similar anatomically & physiologically : Head of clavicle contains layers of cartilage Growth centre Limitations - Unacceptable location of surgical scar - Donor-site complications: Damage to great vessels Instability of clavicle Shoulder instability Clavicle fracture Denials S,JOMS 1987

66. Materials for reconstruction ILIAC CREST

67. Iliac Crest Graft Chondro-osseous graft – full thickness piece of iliac crest including overlying cartilage layer Vertical growth pattern of ilium is converted in graft to multidirectional pattern Donor-site complications: Altered gait herniation of abdominal contents ilium fracture peritonitis KUMMOONA 1986 : No cases of reankylosis in 18months Kummoona , J Maxillofac Surg 1986

68. Materials for reconstruction FIBULA GRAFT

69. Fibula Graft Tubular in shape, densely cortical Easily adapted to passively fit in glenoid fossa Vascularized & Non -vascularized LIMITATIONS : Lacks articular cartilage Donor-site morbidity: great toe flexion contracture, ankle stiffness & weakness and numbness of lateral side of leg

70. Materials for reconstruction METATARSAL GRAFT

71. Metatarsal Graft Provide good supply of articular cartilage combined with up to 7 cm of vascularized bone Smaller than TMJ, so it easily fits within confines of glenoid fossa Intact epiphysis in transplanted MTP joint contains epiphyseal growth plate

72. Materials for reconstruction TRANSPORT DISTRACTION

73. Transport Distraction Osteogenesis STUCKI-MCCORNICK – First to apply DO in 2 cases of tumour involving condyle in 1997 Bone regeneration at trailing edge of transport disc Bridging defect without bone graft Advantage : formation of cartilaginous capsule at end of transport disc Divya Mehrotra, J Oral Biol Craniofac Res. 2012 Harry C,J Oral Maxillofac Surg 66:718-723, 2008

74. Transport Distraction Osteogenesis Indications: Reankylosis cases/ mutiple operations Thick scar tissue impedes vascularity - Poor implant survival Reverse L corticotomy from sigmoid notch to 10 mm from angle Distractor secured on pins in predetermined angle Muralee Mohan C. Nitte University Journal of Health Science 2014

75. DIVYA

76. preop Post distraction 6 mos f/u

77. Sternoclavicular joint TDO

78. MERITS Proportional & harmonic modification of muscles & surrounding soft tissues Reestablishing correct function of soft & skeletal tissues DEMERITS lengthy procedure, compliance Pin-tract, bone infection, psychological problems Vigorous post op PT- pseudo arthrosis at osteotomy site Long term? Divya Mehrotra, J Oral Biol Craniofac Res. 2012

79. Materials for reconstruction HYDROXYAPATITE COLLAGEN BLOCK

80. Hydroxyapatite Collagen Block Pre-shaped Hydroxyapatite collagen block with PRP Carriers for PRP provide scaffold for neocondyle formation 10 cases – 18 months f/u Disadvantages: - wear or failure of material - Giant cell foreign body reaction - Displacement or fracture of block

81. Materials for reconstruction TOTAL TMJ REPLACEMENT SYSTEM

82. Mercuri et al. specifed the indications of TJR Recurrent fibrous or bony ankylosis not responsive to the modalities of treatment which have been applied Failed (bone and soft) tissue grafts Loss of vertical mandibular height and occlusal relationship due to bone resorption, trauma, developmental abnormalities, or pathological lesions Severe inflammation of TMJ involving damage to its structures and lack of response to other treatment methods.

83. TOTal TMJ Replacement ‘‘Ball & socket’’ type prosthetic joint similar to a hip implant. Initially fossa-only prostheses/ only prosthetic condylar part ( unacceptable bone resorption and prosthetic device failures) Total Joint replacement

84. Total TMJ Replacement Effectively deals with distorted anatomy No vascularity issues – recurrent cases No need for second surgical site Release & asymmetry correction together L.M. WOLFORD,IJOMS 2003

85. Complications Methods of RCU reconstruction Reankylosis   Resorption   Deviation upon mouth opening Occlusal Discrepancy n N % n N % n N % n N % Ankylotic mass   2 22 9.09 4 22 18.18 6 22 27.27 5 22 22.72 Coronoid   3 36 8.33 4 36 11.11 4 36 11.11 3 36 8.33 CCG   6 34 17.64 9 34 26.47 15 34 44.11 11 34 32.35 VRO & LRO   1 49 2.04 49 49 49 Total   12 141 8.51 17 141 12.05 25 141 17.73 19 141 13.47   Note: (n = Number of events, N =Number of joints per subset

86. Situations TECHNIQUE JUSTIFICATION 1. <8 years a) With facial asymmetry CCG/SCJ +/- eventual high condylectomy Potential for growth Treat overgrowth like condylar hypertrophy b) Without facial asymmetry Coronoid Graft Potential for growth not required Cannot do ramus osteotomy because of ramal width 2. > 8 years a) With prominent antegonial notch Vertical ramus Osteotomy Reduces antegonial notch b) Without prominent antegonial notch L-shaped ramus Osteotomy Adequate ramal size Maintains height of ramus 3. Re ankylosis a) Child Ramal Transport distraction Free graft will not take in scar tissue Alloplastic joint will not grow b) Adult TJR Best option for scarred tissue

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