TMJ ANKYLOSIS of the Jaw and its clinical significancies

tmj ankylosis

1. TMJ ANKYLOSIS (Overview of the topic) Presented By:- Dr. Vaibhav Bibe 1 st year OMFS PG.

2. The TMJ complex consists of the mandibular condyle which articulates against the articular fossa of the temporal bone; the articular disk; retrodiskal tissue; synovium; ligaments; and associated muscles. Unique due to bilateral articulation, as well as a rigid closure due to occlusion of the teeth. Functionally, the TMJ is a compound joint, with four articulating surfaces: (1) articular surface of the temporal bone; (2) mandibular condyle; (3) superior surface of the articular disk; and (4) inferior surface of the articular disk. The articular disk translates along the articular surface of the temporal bone, and the condyle undergoes rotational hinge movement against the articular disk. This hinge-glide function makes the TMJ a ginglymoarthrodial joint.

3. Embryology of TMJ and condyle:- Begins to develop by the 10 th week of gestation. Superior to condylar blastema a band of mescenchymal cells develops that eventually differentiate into disk. Develops from 2 mescenchymal condensation ( blastemas ) MC will differentiate into osteoblasts and lay down the membraneous bone Condyle has high degree to clacification than temporal bone In the centre of the condyle cartilage developes,that’s the secondary cartilage Ref : Inderbir_Singh’s_Human_Embryology 11 th edition; Langman's Medical Embryology 14 th edition.

4. The disk continues anteriorly with the developing lateral pterygoid muscle. Posteriorly by a ligament with the superior end of meckels cartilage which will develop into malleus of the middle ear. Inferior fibers encircles the anterior malleolar ligament (remnants of Meckel's cartilage) and the chorda tympani and inserts on to the tympanic wall of the temporal bone. This attachment develops into discolamellar ligament Further in postnatal life this inserts its fibers into the squamotympanic fissure (apparently looses its attachment with malleus). Embryology of Articular disk:- Ref : Inderbir_Singh’s_Human_Embryology 11 th edition; Langman's Medical Embryology 14 th edition.

5. TMJ is biarthrodial , ginglymoid , synovial and freely movable joint. CONSISTS OF : - Mandibular condyle which articulates against the articular fossa of the temporal bone. The articular disk. Retrodiskal tissue. Synovium. Ligaments. A ssociated muscles. TMJ ANATOMY Ref : Petersons Principles of Oral & Maxillofacial Surgery 4 th edition.

6. TMJ ANATOMY Ref : Petersons Principles of Oral & Maxillofacial Surgery 4 th efdition .

7. Introduction: - Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by limitation of mouth opening, causing difficulty in mastication, speech, and oral hygiene. The term “ ankylosis ” is of Greek origin (from the Greek word α γκυλος meaning: bent or crooked) and corresponds to a “stiff joint”. Causes : A) Trauma (31–98%) B) Local or systemic infection (10–49%) C) Systemic disease (10%). Ref : Oral and maxillofacial surgery for the clinicians; Xia L, An J, He Y, Xiao E, Chen S, Yan Y, Zhang Y. Association between the clinical features of and types of temporomandibular joint ankylosis based on a modified classification system. Sci Rep. 2019 Jul 19;9(1): 10493.

8. Classically, hemarthrosis following trauma is the pathogenic factor for bone formation in TMJ ankyloses. Hypothesis of hypertrophic nonunion by Yan et al. Dual effect of mouth opening on recent condylar trauma . Pathogenesis: - Ref : Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis . Head Face Med. 2014 Sep 4;10:35 .

9. TMJ disc displacement or rupture, severe damage to both articular surfaces, and close contact of traumatic articular surfaces . Trauma to the condyle causes disruption of the capsu l ar ligament and adjoining periosteum haemarthrosis Organization of intra-capsular haematoma bone formation from the disrupted periosteum or from metaplasia of nonosteogenic connective tissue Bony Ankylosis Ref : Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis . Head Face Med. 2014 Sep 4;10:35 .

10. Ref : Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis . Head Face Med. 2014 Sep 4;10:35 .

11. Duration of POST trauma period ------------------------------------ Age α SEVERITY TMJ ANKYLOSIS

12. CLASSIFICATION EXTENT – TOPAZIAN 1964 SAWHNEY’S CLASSIFCATION ( 1986 ) HETEROTOPIC BONE FORMATION - TURLINGTON AND DURR (1993) RECENT CLASSIFICATIONS DONGMEI HE AND COLLEAGUES (2011) CDA Classification Ref : Oral and maxillofacial surgery for the clinicians.

13. 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. (1) TOPAZIAN Classification(1964):- Ref : Oral and maxillofacial surgery for the clinicians.

14. Sawhney’s classification (1986 ) Type 1: Minimal bony fusion but extensive fibrous 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.

15. TYPE 1 TYPE 2 TYPE 3 TYPE 4 Xia L, An J, He Y, Xiao E, Chen S, Yan Y, Zhang Y. Association between the clinical features of and types of temporomandibular joint ankylosis based on a modified classification system. Sci Rep. 2019 Jul 19;9(1):10493.

16. 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 ankyloses. Turlington and Durr (1993 ) Ref : Oral and maxillofacial surgery for the clinicians.

17. Type A1 : Fibrous ankylosis without bony fusion of joint. Type A2 : Bony fusion on lateral side of joint, residual condyle bigger than half of condylar head on medial side. Dongmei He and Colleagues (2011 ) Ref: He D, Yang C, Chen M, Zhang X, Qiu Y, Yang X, Li L, Fang B. Traumatic temporomandibular joint ankylosis : our classification and treatment experience. J Oral Maxillofac Surg. 2011 Jun;69(6):1600-7.

18. Type A3: Similar to A2 but residual condylar fragment is smaller than half. Type A4: Ankylosis with complete bony fusion of joint.

19. Clinical features: - Partially or completely restricted in opening, protrusion, and lateral excursions . Palpation of joint movements. Issues with mastication, digestion, speech, and oral hygiene. Mandibular incisors often show supra-eruption and labial tipping. Shortened lower face . Marked antegonial notch. The long-standing contractions of the masticatory muscles also give rise to elongation and thickening of the coronoid process, ramal shortening, and chin recession Ref : Oral and maxillofacial surgery for the clinicians.

20. Unilateral Ankylosis Facial Asymmetry. Deviation of chin to the affected side. Flatness and elongation of unaffected side. Effect on maxillary growth. Class 2 malocclusion. Posterior crossbite . Cant of occlusion plane. Reduced mouth opening. Ref : Oral and maxillofacial surgery for the clinicians.

21. Bilateral Ankylosis Micrognathic symmetrical mandible. Bird face deformity. Andy Gump deformity. Obtuse cervicomental angle. Antegonial notching. Protrusive maxillary incisors. Severe malocclusion, crowding of teeth. Ref : Oral and maxillofacial surgery for the clinicians.

22. Radiographic features: - Enlarged condyle T hickened temporal bone Excessive bone formation A radiolucent zone in the bony fusion area. Bony fusion is located in the lateral part The medial non-bony fusion area . Ref : Oral and maxillofacial surgery for the clinicians.

23. Radiolucent zone Recently, Li et al. [19] analysed 10 specimens including 1 of fibrous ankylosis and 9 of bony ankylosis . In particular , to acquire histological information in the radiolucent zone, they carefully protected this part of the tissue during the operation [19]. They found fibrous and cartilaginous tissue in the joint space of fibrous ankylosis . The tissue in the radiolucent zone of bony ankylosis was cartilage and new bone matrix, and bony fusion was formed by new osteophytes progressing towards the centre of the ankylotic mass [19]. They concluded that bony ankylosis was formed by endochondral ossification and osteophyte proliferation Radiography showed that the radiolucent zone presented as a low-density line inside the fusion area. Its histopathological feature was the residual joint space manifested as a compound tissue structure of fbrous , cartilaginous , and osseous tissue. In our previous research21, CT fndings were consistent with histologic results. Type II and III ankyloses were cartilaginous bony ankylosis , with similar components but with diferent degrees of severity. Tis could explain why some patients with bony ankylosis of TMJ can open their mouth to some degree but others cannot. Ferretti et al. 22 evaluated the joint morphology on coronal CT images and concluded that all the ankylosed joints exhibited a persistent rudimentary joint space. Ferretti et al. 22 and Casanova et al. 23 inferred that the radiolucent area inside the lesion represented a remnant of the inter-articular disc. We believe that the radiolucent zone may represent the course of bone healing of two traumatic articular surfaces with interference from the mouth-opening movements. Tis zone can be regarded as a mark of bony fusion development to a certain stage.

24. Preoperative Investigations:- Detailed history,complete clinical examination,professional photographsfor documenting the: (a ) Age of onset of ankylosis ( b) Type, duration, and extent of ankyloses ( c) Type of joint injury or infection ( d) Maximal interincisal opening ( e) Dental characteristics and occlusion (f ) Type of facial deformity ( g) Previous surgery Routine hemogram and pre-op major investigation. Radiographic evaluation.

25. 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 ).

26. 2.PA cephalogram : - Chin deviation—Cg-ANS-Me (Crista Galli - Anterior Nasal Spine - Menton ) ( ii) Occlusal cant ( iii) Grummon’s analysis

27. 3.Lateral cephalogram : - Ramal length: Ar -Go ( Articulare-Gonion ) Corpus length: Go- Pog ( Gonion-Pogonion ) Pharyngeal airway space ( PAS) N perpendicular to Pog ( Nasion perpendicular to Pogonion )

28. 4.Facial CT scan: Three-dimensional anatomy of bony morphology Any anatomical measurements as and when required, e.g., size of ankylotic mass, location of ligula, airway space volume, etc. https://radiopaedia.org/cases/temporomandibular-joint-ankylosis-3

29. 5.CT Angiography :- Required 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.

30. Management Surgical Management is decided by the age of onset , i.e . whether pediatric or an adult . The goals of TMJ ankylosis treatment are to achieve adequate mouth opening and functional occlusion, to prevent recurrence, to promote mandibular growth in the pediatric population, and to correct asymmetry in adults.

31. 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 Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009; Oral and maxillofacial surgery for clinicians

32. Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

33. STEP 1 Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

34. Lining the joint with temporalis fascia or cartilage Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

35. C, then elevated and rotated over the zygomatic arch. D, Flap lining glenoid fossa and sutured to medial soft tissue. TM, deep portion of temporal muscle; TF, temporalis flap; GF, medial aspect of glenoid fossa.

36. Reconstruction of the ramus with a costochondral graft Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

37. Diagrammatic representation of CCG and temporalis flap in place. Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

38. Early Mobilisation and aggressive physiotherapy After release of the MMF (for patients reconstructed with the CCG) and immediately postoperatively for patients reconstructed with DO, the physical therapy program is begun. Early mobilization of jaw; if DO used to reconstruct RCU, mobilize day of surgery; if CCG used, early mobilization with minimal intermaxillary fxation (not > 10 days) Ref : Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009; Oral and maxillofacial surgery for clinicians

39. Surgical Options for Ankylosis Gap Arthoplasty

40. Topazian compared gap and interpositional arthroplasties and reported 53 % incidence of recurrence, when the gap arthroplasty method was used without interposition. . Ref : Sharma H, Chowdhury S, Navaneetham A, Upadhyay S, Alam S. Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study. J Maxillofac Oral Surg. 2015 Sep;14(3):565-72. doi : 10.1007/s12663-014-0686-9. Topazian RG. Etiology of ankylosis of the temporomandibular joint: analysis of 44 cases. J Oral Surg Anesth Hosp. 1964;22:227–233 Arthroplasty without interposition requires a gap of 10–20 mm and often results in mouth deviation

41. Various interpositional graft materials documented in literature that were in use or are currently utilized for placement after gap arthroplasty REF: TMJ Disorders by Darpan Bhargava

42. Alloplastic Total TMJ Replacement (TJR )

43. NEW CLINICAL CLASSIFICATION AND TREATMENT STRATEGIES FOR TEMPOROMANDIBULAR JOINT ANKYLOSIS R. Bi, N. Jiang, Q. Yin, H. Chen, J. Liu, S. Zhu: A new clinical classification and treatment strategies for temporomandibular joint ankylosis . Int. J. Oral Maxillofac . Surg. 2020; 49: 1449–1458. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved CDA CLASSIFICATION

44. REFERENCES: - Inderbir_Singh’s_Human_Embryology 11 th edition Langman's Medical Embryology 14 th edition Petersons Principles of Oral & Maxillofacial Surgery 4 th edition Oral and maxillofacial surgery for the clinicians TMJ Disorders by Darpan Bhargava Stocum DL, Roberts WE. Part I: Development and Physiology of the Temporomandibular Joint. Curr Osteoporos Rep. 2018 Aug;16(4):360-368. doi : 10.1007/s11914-018-0447-7. Xia L, An J, He Y, Xiao E, Chen S, Yan Y, Zhang Y. Association between the clinical features of and types of temporomandibular joint ankylosis based on a modified classification system. Sci Rep. 2019 Jul 19;9(1):10493. Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis . Head Face Med. 2014 Sep 4;10:35. He D, Yang C, Chen M, Zhang X, Qiu Y, Yang X, Li L, Fang B. Traumatic temporomandibular joint ankylosis : our classification and treatment experience. J Oral Maxillofac Surg. 2011 Jun;69(6):1600-7. Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009; Oral and maxillofacial surgery for clinicians Topazian RG. Etiology of ankylosis of the temporomandibular joint: analysis of 44 cases. J Oral Surg Anesth Hosp. 1964;22:227–233 Sharma H, Chowdhury S, Navaneetham A, Upadhyay S, Alam S. Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study. J Maxillofac Oral Surg. 2015 Sep;14(3):565-72. doi : 10.1007/s12663-014-0686-9. R. Bi, N. Jiang, Q. Yin, H. Chen, J. Liu, S. Zhu: A new clinical classification and treatment strategies for temporomandibular joint ankylosis . Int. J. Oral Maxillofac . Surg. 2020; 49: 1449–1458. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

45. THANKYOU

46. It is noteworthy that failure to induce ankylosis by the haemarthrosis experiment [40] cannot negate the rationality of the hypothesis. The injection of blood into the joint space is different from an intra-articular haematoma caused by the impaction of the condylar head against the articular fossa. In the latter, the underlying bone marrow space of the condyle is exposed, which may delivery mesenchymal stem cells (MSCs) into the joint space for osteoblastic differentiation [45,46]. In addition, even simple autologous blood injection into the TMJ can effectively treat chronic recurrent TMJ dislocation through fibrotic changes of the joint [

47. Bone malunion article: https://www.ncbi.nlm.nih.gov/books/NBK554385/#:~:text=Hypertrophic%20Nonunion%20%5B7%5D,of%20callus)%2C%20but%20inadequate%20stability