TMJ ankylosis and reconstruction.pptx

Detailed presentation on TMJ ankylosis and reconstruction by Dr.Kathirvel.G M.D.S (OMFS).,

1. TMJ A nkylosis and Reconstruction DR.G.KATHIRVE L PG-OMFS

2. Contents: Introduction Etiology Pathophysio logy Classification Clinical features Investigations M anagement Surgical approaches Surgical technique Complications

3. TEMPOROMANDIBU LAR JOINT ANKYLOSIS Introduction : The word “ankylosis” is of Greek origin and means a stiff joint . It may be classified as fibrous, fibro-osseous, or osseous union of the components of the joint. Trauma is the major cause, others being rheumatoid arthritis, degenerative arthritis, infectious spondylitis, and psoriasis. Definition: Bony or f i brous adhesion of the anatomic joint components accompanied by limitation of mouth opening, causing diffculty in mastication, speech, and oral hygiene. Michael Miloro ; Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition ; PEOPLE’S MEDICAL PUBLISHING HOUSE—USA; 2011

4. ETIO LOGY Trauma (31–98%) Condylar trauma may lead to hemarthrosis due to injury to the periosteum and capsular ligament. When this intracapsular hematoma organizes, hypertrophic bone is formed from the disrupted periosteum or metaplasia of non-osteogenic connective tissue. This may lead to hypomobility and bony ankylosis may eventually develop. local or systemic infection (10–49%) Otitis media or mastoiditis or parotitis or from the hematogenous route —tuberculosis, gonorrhea, scarlet fever, etc. Systemic disease (10%). Ankylosing spondylitis, rheumatoid arthritis or psoriasis. Kaban LB, Perrott DH, Fisher K.  A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg. 1990;48:1145–51.

5. Laskin (1978) Genesis of ankylosis following trauma to the mandible Age of the patient: Younger patients Higher osteogenic potential and rapidity of repair Anatomical differences - more chance of comminution, frequent medial displacement head, glenoid fossa fractures . Damage to the disk. Severity of trauma: The degree of trauma influences the extent of damage to the condyle, disk and fossa, as well as degree of displacement of the condyle. Kishore Nayak; Chapter 78 - Ankyo l sis of Temporomandibu lar joint; Peter Ward Booth ; Maxillofacial surgery; 2nd edition Vo lume 2; Churchill livingsto; 2006

6. Laskin (1978) Genesis of ankylosis following trauma to the mandible Site of fracture Intracapsular injuries have a greater propensity for leading to ankylosis. Rowe explained that the condyle in a younger person is poorly adapted and tends to burst open the condyle, causing severe hemarthrosis Duration of immobilization Articular disk Direct contact between a comminuted condyle and glenoid fossa , either from a displaced or a torn meniscus, is the key factor in the development of ankylosis. Kishore Nayak; Chapter 78 - Ankyo l sis of Temporomandibu lar joint; Peter Ward Booth ; Maxillofacial surgery; 2nd edition Vo lume 2; Churchill livingsto; 2006

7. Pathophysiology : Intra capsular Fracture of the bone Bleeding within joint cavity ( Heamarthrosis ) Bone fragments with high osteogenic potential Organisation of hematoma within joint Conversion to fibrous tissue Followed by bone formation

8. Inciting event (Trauma) leads to three main events 1- D isc displacement with severe injury to the articular surfaces with formation of intra-articular hematoma rich in osteo progenitor cells (peri vascular undifferentiated pluri potential mesenchymal cells-PUPMC). 2- Change in local tissue environment includes disturbances involving the microvasculature and changes in oxygen tension, pH (Alkaline) and blood flow . These local changes supports osteogenesis. 3-Trauma signal lead to local release of osteo inductive cytokines especially bone morphogenic proteins (BMP), members of the transforming growth factor-B (TGF-B) super family and genes that synthesize osteoid and chondroid (matrix) are activated. These lead to differentiation of the PUPMC into osteoblasts or chondroblasts start lay down of new bone.

9. Dual effect of mouth opening on new bone formation in recent condylar trauma Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

10. CLASSIFICATION Kazanj ian (19 38 ) True a nkylo sis (Intra articu l ar) Fa l se a nkylo sis (Extra articu l ar) Varsha Haridas Upadya ; Classification and surgical management of temporomandibular joint ankylosis: a review; J Korean Assoc Oral Maxillofac Surg 2021;47:239-248

11. CLASSIFICATION Topazian (1964) • Stage 1: Ankylotic bone limited to the condylar process • Stage 2: Ankylotic bone extending to the sigmoid notch • Stage 3: Ankylotic bone extending to the coronoid process Varsha Haridas Upadya ; Classification and surgical management of temporomandibular joint ankylosis: a review; J Korean Assoc Oral Maxillofac Surg 2021;47:239-248

12. Sawhney’s classifcation (1986) Type 1: Minimal bony fusion but extensive f i brous adhesions around the joint Type 2: Bony fusion at the outer edge of the articular surface but no fusion on medial area of the joint Type 3: Bridge of bone between the mandible and temporal bone Type 4: Joint is replaced by a mass of bone Varsha Haridas Upadya ; Classification and surgical management of temporomandibular joint ankylosis: a review; J Korean Assoc Oral Maxillofac Surg 2021;47:239-248

13. Turlington and Durr (1993) According to heterotopic bone formation within the ankylotic mass Grade 0: No bone islands visible Grade 1: Islands of bone visible within the soft tissue around the joint Grade 2: Periarticular bone formation Grade 3: Apparent bony ankylosis Grades 1, 2, and 3 are further classifed as symptomatic (S) and asymptomatic (A) Varsha Haridas Upadya ; Classification and surgical management of temporomandibular joint ankylosis: a review; J Korean Assoc Oral Maxillofac Surg 2021;47:239-248

14. Hakim and Metawalli Classification (2002): As per Axial CT Scan

15. Dongmei He and Colleagues (2011)

16. Yan and colleagues (2014) Based on its development, ankylosis can be classifed into three phases: • Fibrous-chondral phase demonstrating fbrous tissue and chondrocytes occupied the joint gap • Chondral-calcifed cartilage phase manifesting abundant chondrocytes, cartilage matrix, and neo-formative endochondral ossifcation in the joint space • Bone-cartilage phase showing compacted bone bridge in the lateral joint gap and cartilage in the medial joint gap Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

17. Braimah et al. Modification of Sawhney’s classification M axillary involvement on CT images Class V J oint architecture completely replaced by bone with fusion of the condyle, sigmoid notch and coronoid process to the zygomatic arch, glenoid fossa and maxilla

18. Long Xia et al. (2019) Based on coronal CT scans Type I: Non bony ankylosis, with the condyle and glenoid fossa clearly seen with scattered callus. Almost normal joint space and no radiolucent line. Type II: Lateral bony ankylosis. The medially displaced condylar fragment, residual disk and fossa form a pseudoarthrosis. Type III: Complete bony ankylosis of the joint with a radiolucent line inside the fusion but no recognizable condyle or fossa. Type IV: Extensive bony ankylosis with no radiolucent line and no joint features seen.

19. ‘C’ - whether the condylar head structure could be preserved C0 - lateral bony ankylosis of both joints with the medially displaced condyle heads preserved C1 - ankylosis of the entire joint presenting with bony fusion and no recognizable condyle or fossa on one or both sides. ‘D’ - whether the patient has any secondary dentofacial deformity D0 - the patient has no significant dentofacial deformities D1 - the patient has dentofacial deformities that affect occlusion and the appearance of the facial profile. ‘A’ - skeletal age of the patient Ac - young patient with active dentofacial growth (skeleton immature) Aa - adult patient with a fully developed dentofacial structure (skeleton mature).

20. C l inica l features: Unilateral Ankylosis : Deviation of the mandible and chin on the affected side. The chin is receded with hypoplastic mandible on the affected side. Roundness and fullness of the face on the affected side. The appearance of the flatness and elongation on the unaffected side. The lower border of the mandible on the affected side has a concavity that ends in a well-defined antegonial notch. Some amount of oral opening may be possible. Class II angles malocclusion on the affected side plus unilateral posterior cross bite on the ipsilateral side seen. Condylar movements are absent on the affected side Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

21. Bilateral cases D ecrease in interincisal opening <5 mm or many times there is nil oral opening. The mandible is symmetrical, but retrognathic / micrognathic . “ B ird face” deformity with receding chin. Convex profile. The neck chin angle may be reduced or almost completely absent. Antegonial notch is well defined No palpable joint movements Class II malocclusion can be noticed. Upper incisors are often protrusive with anterior open bite. Maxilla may be narrow. Multiple carious teeth with bad periodontal health can be seen. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

22. INVESTIGATIONS Orthopantomogram : ( i ) Decreased joint space (ii) Absence/presence of normal condylar and coronoid anatomy (iii) Prominent antegonial notch (iv) Markings for osteotomy cuts (for distraction) Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

23. PA cephalogram: ( i ) Chin deviation—Cg-ANS-Me (Crista Galli - Anterior Nasal Spine - Menton ) (ii) Occlusal cant Grummon’s Ana l ysis Lateral cephalogram: Pharyngeal airway space (PAS) Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

24. Facial CT scan: (i) Three-dimensional anatomy of bony morphology (ii) Any anatomical measurements as and when required, e.g., size of ankylotic mass, location of li n gula, airway space volume, etc Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

25. CT Angiography To assess the relationship of internal maxillary artery to the ankylotic mass. There are chances of the vessel being inside the bone, especially in re-ankylosis cases. Assessment of OSA Epworth sleepiness scale Pittsburgh sleep quality index Polysomnography (PSG) Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

26. Airway Implications of TMJ Ankylosis Assessment McNamara’s airway analysis : Done on lateral cephalogram H elps to assess the Pharyngeal airway space ( PAS) CT : Provides volumetric assessment of the Pharyngeal airway space Polysomnography : Helps to assess the Apneic- hypopneic index.  Moderate to severe AHI may require delayed extubation /tracheostomy Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

27. Sequelae of Untreated Ankylosis Normal facial growth and development affected severely Speech and n utritional impairment Respiratory distress (tongue fall in sleep), especially in bilateral involvement with severe micrognathia. OSA syndrome - triad seen in bilateral ankylosis patients: TMJ ankylosis Severe retrognathia or micognathia Associated OSA Malocclusion Poor oral hygiene Multiple carious and impacted teeth Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

28. MANAGEMENT Objectives: • Restore mouth opening • Restore joint f un ction • Allow for condylar growth • Correct facial profile • Relieve upper airway obstruction Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

29. Options for securing the airway during surgery: • Retrograde intubation • Light inhalational anesthesia with speedy release of ankylosis followed by intubation • Fiberoptically assisted nasotracheal intubation • Awake tracheostomy under local anesthesia • Blind nasal intubation Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

30. El-Sheikh ( 1999) The radical resection of the ankylosed mass via wide surgical exposure Release of the pterygo-masseteric muscle sling with resection of the condylar process Restoration of the vertical ramal height and condylar head by a costochondral graft Simultaneous correction of jaw bone deformities at the same time as release of the ankylosis Careful selection of the patients who are expected to comply with postoperative functional rehabilitation and regular follow-up for at least 1 year Kishore Nayak; Chapter 78 - Ankyo l sis of Temporomandibu lar joint; Peter Ward Booth ; Maxillofacial surgery; 2nd edition Vo lume 2; Churchill livingsto; 2006

31. SURGICAL ANATOMY Nerve Anatomy Facial Nerve The main trunk of the facial nerve exits from the skull at the stylomastoid foramen. Approximately 1.3  cm of the facial nerve is visible until it divides into temporofacial and cervicofacial branches. According to Al-Kayat and Bramley (1979) The distance from the lowest point of the bony external auditory canal (EAC) to this bifurcation measures 1.5–2.8 cm (mean 2.3  cm). The point at which the upper trunk crosses the zygomatic arch may be anywhere from 8 to 35 mm anterior to the most anterior portion of the bony EAC (mean 2.0 cm). If the superfcial layer of the temporalis fascia and the periosteum over the arch is incised within 8 mm, one can prevent injury to the upper trunk branches. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

32. Nerve Anatomy Facial Nerve According to Miloro et al The average distance anterior to bony EAC was 2.12 cm. (1.68–2.49 cm). The temporal branch of the facial nerve emerges from the parotid gland and crosses the zygoma under the temporoparietal fascia to innervate the frontalis muscle in the forehead. Postsurgical palsy manifests as an inability to raise the eyebrow and ptosis of the brow. Damage to the zygomatic branch results in paralysis to the orbicularis oculi. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

33. Nerve anatomy The auriculotemporal nerve courses from the medial side of the posterior neck of the condyle and turns superiorly, running over the zygomatic root of the temporal bone. Preauricular exposure of the TMJ area invariably injures the nerve. Damage is minimized by incision and dissection in close apposition to the cartilaginous portion of the external auditory meatus. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

34. Vascular Anatomy The superfcial temporal artery and internal maxillary artery are the terminal branches of the external carotid artery. In the preauricular approach, the internal maxillary artery runs about 3 mm medial to the mid-sigmoid notch. The most commonly injured artery during temporomandibular procedures is the middle meningeal branch of the internal maxillary artery. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

35. SURGICA L APPROACHES Dingman’s Preauricular Approach: Begins along the course of the helix, just in front of the tragus till the attachment of the ear lobule. Going through the skin and superf i cial fascia, about 2  cm above the zygomatic arch, an oblique incision is made through the superfcial layer of temporal fascia. Just above the arch, the periosteum of the zygomatic arch is incised and turned forward as one f l ap with the outer layer of the temporal fascia, superfcial fascia containing nerves, and skin. The ankylotic mass now stands exposed. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

36. Blair (1914) It is like the Dingman’s incision in preauricular fold, but unlike the former it bends in the region of the zygomatic arch like a hockey stick. The disadvantages include an unsightly scar and possible damage to the frontal branch of the facial nerve Thoma (1945) The vertical limb is in the preauricular fold but angulated at 45° in the hairline near the bifurcation of the superfcial temporal vessels Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

37. Al-Kayat and Bramley (1979): This reverse question mark cosmetically acceptable incision gives excellent access to the TMJ without causing any damage to important anatomical structures. It starts superiorly through the scalp in the temporal region and extends to the inferior tragus. The superfcial layer of the temporalis fascia is identifed and incised at the root of the arch at 45° anterosuperiorly to avoid branches of the facial nerve. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

38. Popowich’s Modifcation of Al-Kayat and Bramley: This approach to the zygomatic arch and joint gives excellent visibility with safety. It is longer and wider than the conventional and question mark shaped and begins about a pinna’s length away from the ear, anteroposterior just 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 Endaural: Rongetti in 1954, with the incision carried in the external ear. Advantages are good aesthetics and excellent access to the TMJ.  Disadvantages include perichondritis, infection, paresthesia of the pinna, and deformity of the ear. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

39. Rhytidectomy The preauricu l ar incision is extended in a curvilinear fashion around the mastoid tip, with an S-shaped extension ending in a submandibular incision. This allows access to the entire posterior border of the mandible and allows for identifcation of the main trunk of the facial nerve. Postauricular Alexander in 1975 Advantage is that it avoids facial nerve injury and salivary fistula. Possible complications include stenosis of external auditory canal, infection, and paresthesia of the pinna. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

40. Hind’s/Retromandibular Approach A skin incision is placed 1 cm behind the ramus of the mandible and extends 1 cm below the lobe of the ear to the angle of the mandible. Communicating fascia between the sternomastoid muscle and the parotid gland and masseter muscle (parotidomasseteric fascia) is carefully separated, to expose the posterior border of the ramus. Perforation of the posterior facial vein and injury to the main trunk of the facial nerve is avoided. Once the posterior border of the ramus has been exposed, the pterygomasseteric sling is incised at the angle and the masseter muscle, parotid gland are reflected upward and laterally and the periosteum is incised sharply to expose the neck of the condyle. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

41. Hind’s/Retromandibular Approach Advantages: Shorter working distance from the skin incision to the condyle; Good access and visualization of the posterior border of the mandible and sigmoid notch, facilitating fracture manipulation and reduction Well hidden or inconspicuous scar. Disadvantage Access to the joint space and anteromedially displaced condylar head is very limited. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

42. Surgical technique : An incision of 4 cm is made at the buccal shelf . The location corresponds to the area of the anterior border of the mandibular ramus and the external oblique ridge. The posterior incision extending upwards should not be higher than 5 mm above the occlusal plane to avoid injury to the buccal nerve as a result of severence or traction. The soft tissue from the inner and outer surface of the mandibular ramus and portions of the mandibular angle is reflected.

43. The malleable retractor is introduced onto the inner surface of the coronoid process and the channel retractor placed at the posterior border for surgical field and soft tissue protection. The coronoid process is cut off with a reciprocating saw and displaced into the inner surface for better access so the ankylosed area is visible. Reflection of the scar tissue from both inner and outer surfaces of the ankylosed area is accomplished as much as possible with the periosteal elevator.

44. A malleable retractor is then placed at the inner aspect of the ramus to protect the internal maxillary artery that lies immediately deep to the condylar neck and the channel retractor moved upwards for better access to the ankylosed area. A gap is created with a round bur and No. 703 bur at the planned condylar neck area to separate the mandible and the ankylosed area

45. SURGICAL TECHNIQUES Condylectomy Gap arthroplasty Interpositional arthroplasty Total joint reconstruction Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

46. Condylectomy Indications: In cases of fibrous ankylosis , where the joint space is obliterated with deposition of fibrous bands, but there is not much deformity of the condylar head The condylectomy procedure can be carried out via preauricular incision. After surgical exposure one can see the demarcation between the roof of the glenoid fossa and the head of the condyle. Horizontal osteotomy cut is carried out with the help of the surgical bur at the level of condylar neck. Vital structures on the medial surface of the condylar neck should be protected, by using special condylar retractor, inserted prior to the bony cut. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

47. Condylectomy The condylar head, which is sectioned from ramus, then should be separated from the superior fibrous attachments carefully and removed. The rest of the ramal stump should be smoothened out and wound closed in layers. Unilateral condylectomy tends to cause deviation of the mandible towards the operated side on oral opening B ilateral condylectomy tends to cause anterior open bite as a result of the loss of height in the vertical rami. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

48. Gap Arthroplasty / Osteoarthrectomy The term gap arthroplasty is therefore, used to describe the operation, in which the level of section is below that of the previous joint space and in which, no substance is interposed between the two cut bony surfaces. Resection of the bony mass consists of two horizontal osteotomy cuts and removal of a bony wedge for creation of a gap between the roof of the glenoid fossa and ramus. Here, it is recommended to create a minimum gap of at least 1–1.5 cm to prevent reankylosis . Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

49. Gap Arthroplasty/Osteoarthrectomy The width of the bone removed is considered crucial. It is not usually possible to remove the entire block in toto, particularly from the medial aspect, which is in close proximity to the internal maxillary artery. Hence, bone is removed carefully by using a large round bur, until the medial bone is thinned out enough to be readily removed by using hand chisel or osteotome. It is important to create a gap of equal dimension both laterally and medially, so that the possibility of medial reankylosis due to bone contact is avoided. Recurrence rate reported recently in the literature after only gap arthroplasty is around 60%. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

50. Advantage: Simple procedure and requires a short surgical time. Disadvantages: (1) C reation of a pseudoarticulation (2) S hort mandibular ramus with anterior open bite in bilateral cases and posterior open bite in unilateral cases (3) H igh recurrence rate. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

51. Esmarch’s Procedure This is of historical signifcance only. S mall 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. D isadvantage : T he osteotomy is in the ramus, no ramal osteotomy or distraction can be done for correction of facial deformity. Hence, it is no longer used for ankylosis release. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

52. Lateral Arthroplasty (LAP) Nitzan hypothesized that in Sawhney’s Type II TMJ ankylosis , if the integrity and location of the displaced condyle and disc can be determined (despite morphological and positional alterations), both could be preserved to fulfll their roles in mandibular growth and function. Only the lateral part of the ankylosed mass was resected. Disadvantage: R esidual condyle continues to grow after LAP Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

53. Coronoidectomy: A fter gap arthroplasty is carry out ipsilateral and contralateral coronoidectomy to be done as per the indications. Ipsilateral procedure can be done through the same external incision. In case of unilateral ankylosis, contralateral procedure can be done through intraoral incision. A hole can be drilled at the tip of coronoid and a wire threaded through it, before the cut to have better control. The osteotomy cut extends from the depth of the sigmoid notch to the junction of the horizontal and vertical rami of the mandible. It is always desirable to excise the coronoid rather than release it and allow it to be pulled up superiorly by the temporalis muscle. Unless the coronoid process is removed, there is potential for reankylosis after reattachment . Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

54. Type I: C omplete osseous union of the osteotomised segment to the ramus Type II: F usion of the coronoid process to the ramus was limited to the posterior part of the segment, with a wedge-shaped gap appreciable at the anterior aspect Type III: C omplete separation of the sectioned coronoid process with the mandibular ramus, with a posterosuperior rotation of the segment into the temporal fossa. R eattachment of the coronoid process in a more favourable position, without significantly reducing the inter-incisal opening

55. Interpositional Arthroplasty Verneuil in 1860 proposed that r ecurrence rate of ankylosis can be lessened, when something is interposed between the two cut raw bony surfaces Interpositional arthroplasty involves the creation of a gap, but in addition a barrier (autogenous or alloplastic) is inserted between the two cut bony surfaces to minimize the risk of recurrence/fusion again and to restore/maintain the vertical height of the ramus Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

56. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

57. T emporalis myofascial fla p Deep temporalis fascia along with a varying thickness of superficial layer of temporalis muscle may be harvested as an axial pattern vascularized flap based on the middle and deep temporal arteries and veins. The flap is sutured medially, anteriorly and posteriorly to the soft tissues with 4-0 monocryl suture. The dependable rich blood supply, the proximity to the TMJ and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly, makes this a versatile flap for lining the glenoid fossa, without any donor site morbidity. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

58. B uccal pad of fat (BPF): This was first reported by Dr Vidya Rattan in 2006 Harvesting technique: After complete removal of the ankylotic mass through temporal approach, the BPF can be easily harvested through the same incision. Blunt dissection is done anteromedial to coronoid process. Artery forceps is used to nick the periosteum just anterior to the coronoid process. External pressure over the cheek, while doing dissection facilitates the visualization of BPF. Once visualized, it can be gently pulled with the help of one artery forceps, while doing blunt dissection with other artery forceps. It easily herniates into the surgical field and has sufficient volume to fill the gap created by removal of ankylotic mass. It prevents heterotopic bone formation by completely blocking the dead space and not allowing the formation of hematoma. Fat also converts the microenvironment from osteogenic to adipogenic, thus inhibiting osteogenesis. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

59. Advantages BPF graf t : Less chance of resorption of BPF as it is pedicled and blood supply is maintained. The fat graft survives by neovascularization and neoadipogenesis. C hances of development of re-ankylosis are eliminated. The treatment is also less traumatic than autogenous joint reconstruction and more cost efficient than alloplastic reconstructive procedures.

60. Abdominal fat graft: For this harvest periumbilical incision is taken A fter undermining of the skin, C omposite abdomal fat is harvested F illed into the arthroplasty gap and secured with sutures. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

61. A uricular cartilage grafts 3- to 4-cm incision on the posterior of the auricle. Along the rim of the auricular concha, the proximal “boat-like” portion of the concha cartilage was removed with the antehelical rim maintained. The removed cartilage graft is convex and fits the fossa well. A piece measuring 2 X 2 cm is adequate to line the fossa. The grafts were inserted into the appropriate position between the condyle and fossa and firmly sutured to anterior, lateral and posterior peripheral soft tissues with 4 to 6 resorbable sutures.

62. Temporomandibular Joint Reconstruction

63. Reconstruction of Ramus-condyle Unit 1. Reconstruction with autogenous grafts l ike CCG or SCG 2. Reconstruction using transport distraction osteogenesis 3. Total joint replacement by using alloplastic TMJ prostheses . Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

64. Rationale for RCU Reconstruction The goal of RCU reconstruction in TMJ ankylosis includes restoration of ramal height. A voids occlusal discrepancies and deviation on mouth opening in unilateral cases and anterior open bite in bilateral ankylosis . In bilateral TMJ ankylosis after gap arthroplasty without RCU reconstruction, there are increased chances of OSA because the ramus falls back due to lack of posterosuperior stop. R estoring normal jaw movement and a symmetric mandible will allow future soft and hard tissue development. D ecrease in facial asymmetry by giving as near normal anatomy Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

65. Reconstruction with autogenous grafts Autogenous Bone Grafting Costochondral (rib) graft Sternoclavicular joint Coronoid graft Ramus graft Calvarium Iliac crest Fibula Second, fourth or fifth metatarsophalangeal joint Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

66. Costochondral (rib) graft : CCG was first described by Gillies; however, the current technique was popularized by Poswillo. P rocedure: Costochondral graft is harvested through the inframammary incision. Either 5th, 6th or 7th rib is harvested. The length of the total graft will depend on the height of the ramus to be restored. A minimum of 1.5 cm of costochondral junction should be harvested. This should be carved to simulate the shape of condylar head. The graft should be fixed on the lateral aspect of the ramus with the screws or transosseous wires. A minimum gap of 0.5–1 cm should be kept between the graft and glenoid fossa side , so that free movement is possible without any friction.

67. Advantages: Most widely used. The cartilage cap mimics both the bony and cartilaginous components of TMJ. It has got intrinsic growth potential. Easy accessibility and adaption. It can be easily carved as the shape of the condyle—gross anatomical similarity to condyle Donor site complications: Pleural tear, pleural pain, pneumothorax, pleural effusion. Disadvantages : Increased operating time Additional surgical site Donor site morbidity Graft overgrowth Possible potential for reankylosis. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

68. Sternoclavicular joint Graft (SCG): The SCG is the articulation of the clavicle and the manubrium of the sternum. The SCG resembles the TMJ morphologically and histologically and it can be considered as a viable option to CCG. Technique: The SCG is harvested through an infraclavicular incision, 2–3 cm lateral from the condylar head of the SCG. The incision is made first through the skin, subcutaneous tissues, and platysma. The overlying fascia and periosteum are next incised. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

69. Muscle attachment and periosteum are dissected from superior and medial aspects of the clavicle gently, maintaining the integrity of attachment of the ligaments of the articular disk to the clavicular head and avoiding injury to the pleura. Usually a split-thickness graft is procured leaving the inferior part intact. The articulating end of the graft is shaped to simulate the head of the condyle for a better fit into the glenoid fossa. The graft is then fixed on the lateral aspect of the ramus using 1.5 mm × 10 mm screws through a submandibular incision. After fixation of the graft temporalis fascia and muscle is interpositioned on the glenoid fossa side Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

70. Surgical Technique The costochondral graft must be of adequate length to re-establish posterior vertical height . Approximately a centimeter cap of cartilage is required for condylar head reconstruction. Iliac bone graft is harvested in the usual fashion. With a 2.4 mm titanium plate on the buccal surface, the costochondral graft is “sandwiched” between the plate and iliac graft to form a 3-part composite graft. Superior and inferior locking screws are placed. and central nonlocking screw is placed lagging the iliac crest bone to the plate, compressing the costochondral compound and adding to structural integrity.

71. Ramus Osteotomy Pedicled Grafts Y. Liu used the method of total (Vertical ramus osteotomy—VRO) and partial (L- ramus osteotomy—LRO) sliding osteotomy on the posterior border of the ramus for reconstructing the mandibular condyle in TMJ ankylosis. The chances of bony resorption and graft failure of the newly reconstructed RCU are greatly reduced as this segment is a pedicled graft with attachment to the medial pterygoid muscle and periosteum Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

72. Vertical ramus osteotomy : For the VRO, the cut is made in a vertical direction starting from the sigmoid notch to the inferior border of the mandible just lateral to the lingula and parallel to the poste r ior border of the ramus. While retaining an adequate amount of medial pterygoid, the proximal segment is pushed upward to recreate the RCU and plated in the new position. A small triangular chunk of bone just anterior to the osteotomy cut is resected to reshape the lower border and mandibular angle VRO may be performed in cases where a pronounced antegonial notch is present. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

73. Inverted L- ramus osteotomy : A n L-shaped cut is made from sigmoid notch parallel to the posterior border of the mandibular ramus, just lateral to the lingula, till 10 mm above the angle of themandible. The osteotomized segment is shifted upward and fxed with a mini plate creating a gap between the o steotomized segment and remaining mandibular angle. The coronoid process on the affected side is resected, recontoured, and fxed in that gap with another mini plate. The upper part of the ramus is then reshaped like a condyle. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

74. Reconstruction using transport distraction osteogenesis In multiple operated patients, scar tissue forms with each surgery, which may affect angiogenesis due to limited diffusion. Thus, free autogenous tissue grafts, such as costochondral and coronoid grafts often fail in such cases. Hence, transport distraction osteogenesis is considered as an option for RCU reconstruction, especially in re-ankylosis cases in children. Advantages: No donor side morbidity. Allows immediate mobilization of jaw. Relapse rate is much less. Stable occlusion. Disadvantage: Requires patient compliance. Longer duration. Vector control can go wrong, for which proper planning is very important, device can fail. Chances of infection. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

75. Surgical procedure: The mandibular ramus is approached through a 2 cm long incision made below the angle of the mandible. A transport disk is created at the condylar end of ramus with a partially completed reverse L-shaped osteotomy in the lateral cortex with the vertical line extending from the depth of the sigmoid notch to around 10 mm from the angle. The superior portion of this segment is then rounded to simulate new articular condyle head Length of the distractor is selected on the basis of the amount of distraction planned to reach the glenoid fossa. The distractor is placed to mark the osteotomy and screw holes are drilled. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

76. The vector is oriented in such a way that the superio r fragment distracted toward the glenoid fossa. The vascular attachments on the medial side of the disk segment is maintained. The dead space can be filled with a BPF or temporalis flap. The distractor rod is brought out through an additional small stab incision externally. Mouth opening exercises and physiotherapy is started 48 hours after the surgery and continued throughout distraction phase. The activation rod is removed at the end of distraction. The regenerate bone is allowed to consolidate for at least 3 months before removal of distractors through the same submandibular incision. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

77. Total joint replacement by using alloplastic TMJ prosthes i s These are developed through CAD/CAM technology. TMJ reconstruction using artificial prostheses should be delayed until completion of growth. Prefabricated condylar prosthesis are made of surgical steel, vitallium or titanium, chrome cobalt, proplast, teflon, etc. have been used extensively. Fossa liners along with specially constructed TMJ prosthes i s reconstruct the entire joint. The artificial TMJ prosthes i s patients should have a follow-up period of 5–8 years, as such prostheses are associated with problems such as wear, mobility or fracture of the implant, hypersensitivity, a foreign body reaction, and heterotropic bone formation. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

78. Total joint replacement by using alloplastic TMJ prosthes i s Indications: Adult patient with growth completion Failed autogenous CCG/SCG grafting with multiple recurrences. Relative Contraindications Systemic Incomplete facial bone growth (child) Advanced medical-surgical risk Uncontrolled systemic disease Psychological instability Local / Regional Insufficient hard and soft tissues to support the implants Active or recent infection (local or systemic) Allergy to prosthetic materials (rare) Uncontrolled parafunctional oral habit Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

79. Total joint replacement by using alloplastic TMJ prosthes i s Protocols for TMJ Replacement Release the ankylosis Remove the heterotopic and reactive bone/medial stump, etc. Reconstruct the TMJ with total joint prostheses. Pack a temporalis flap or fat graft around the articulation area of the prostheses Perform indicated orthognathic surgery in a single operation Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

80. Advantages Rigid fixation allows immediate postoperative physical therapy. No donor site morbidity. Decreased surgical time (vs. autogenous bone). Mimics normal anatomy (CAD/CAM or patient-fitted TJR). Maintenance of stable occlusion (no remodeling). Can correct apertognathia, retrognathia without potential for relapse Disadvantages Device cost. Material wear and/or failure (screw loosening, fracture). Possible heterotopic bone formation (ankylosis). Possible need for revision and/or replacement. Size and design limitations (stock devices). No growth potential. Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

81. Autogenous Alloplastic Biocompatible Biocompatible Donor site No Donor site Ankylosis potential Low ankylosis (heterotopic bone) Longevity May require revision/replacement Young patient with growth potential Adult patient with growth completion Lack of growth or overgrowth Mechanical wear Neelima Anil Malik ; Textbook of ORAL AND MAXILLOFACIAL SURGERY ; Fifth Edition; JAYPEE BROTHERS MEDICAL PUBLISHERS; 2021

82. Sonal Anchlia ; Chapter 63: Temporomandibular Joint Ankylosis; Textbook of Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

83. THANK YOU