Tmj ankylosis-oral and maxillofacial surgery

etiopathogenesis,classification,sawhney classification,clinical features,diagnosis,management,surgical aproaches,condylectomy,gap arthroplasty,interpositional arthroplasty,kaban's protocal,complications

1. TEMPOROMANDIBULAR JOINT ANKYLOSIS 1 By:Prashanth sharma Final year BDS

2. • Greek terminology meaning ‘stiff joint’. • Fusion between cranium and condyle. • Jaw function is affected. • Hypomobility or immobility of joint can lead to inability to open mouth from partial to complete. 2

3. ETIOPATHOLOGY OF ANKYLOSIS OF TMJ • • • • congenital At birth (forceps delivery ) hemarthrosis condylar # - intra / extra capsul r a Trauma • • • • • Parotitis tonsilitis A b s c e ss a r o u n d t h e j o i n t osteomyelitis of the jaw actinomycosis Infections 3

4. Inflammation • • • Rheumatoid arthritis osteoarthritis Septic arthritis Systemic diseases • • • • • small pox scarlet fever Scleroderma beriberi Ankylosing spondylitis Other causes • • • • bifid condyle p r o l o n g e d t r i s m u s p r o l o n g e d i mm o b i l i z a t i o n B u r n s 4

5. Pathophysiology Trauma ↓ Extravasation of blood into the joint space ↓ Heamarthrosis ↓ Period of restricted mobility due to pain ↓ Fibrosis leading to further restriction ↓ Gradual bone formation 5

6. CLASSIFICATION 1. Based on the location: - - Intra articular or true ankylosis Extra articular or false ankylosis 2. - - - Based on the Bon y . Fib r ous. Mixed. type of tissue involved: 3. Based on the extent of fusion/severity of ankylosis: - - Complete. Incomplete. 4. Based on the side involved: - - Unilateral. Bilateral. 6

7. SAWHNEY CLASSIFICATION 1. Type I : Head of the condyle is flattened or deformed with close approximation to the upper make movement possible. articular surface. Dense fibrous adhesions 2. Type II : Head misshapen or flattened but is distinguishable. Bony fusion of head to outer edge of articular surface. 7

8. 3. Type III : Bony block seems to bridge across ramus and zygomatic arch. Displaced condylar head. Elongation of coronoid process seen. 4. Type IV : Bony block is wide and deep and extends between ramus and upper articular surface thereby completely replacing joint architecture. 8

9. CLINICAL MANIFESTATIONS → Unilateral Ankylosis: • Facial asymmetry. • Deviation of mandible and chin on affected side. • Roundness and fullness of face on affected side. • Cross bite maybe seen. • Lower border of mandible has a concavity on affected side. 9

10. → Bilateral Ankylosis: • Inability to open mouth progresses to decreased interincisal opening. • Typical ‘bird face’ deformity with receding chin. • Neck chin angle reduced or completely absent. • Class II malocclusion. • Protrusive upper incisors with anterior open bite. • Multiple carious teeth with bad periodontal health. 10

11. DIAGNOSIS Diagnosis is based on the following: 1. 2. 3. a. History of trauma, infection etc. Clinical findings. Radiographic findings: O P G : Shows both jo i nts pic t ure which can be co m pa r ed in unila t eral cases. Lateral oblique view : Gives anteroposterior dimension of condylar b. mass. Elongation of coronoid process seen. c. Cephalometric radiograph : Taken to evaluate associated skeletal deformities. 11

12. d. CT scan : • Very helpful guide for surgery. • Relation to middle cranial fossa, anteroposterior width can be assessed. • Any presence of fractured condylar head can be located. 12

13. MANAGEMENT OF TMJ ANKYLOSIS Aims and Objectives of Surgery: 1. Release the ankylosed mass and creation of a gap to mobilize joint. Creation of a functional joint. the 2. 3. 4. 5. 6. To T o T o T o reconstruct the joint and restore vertical height prevent recurrence. restore normal facial growth pattern. of ramus. improve esthetics and rehabilitate the patient. Surgical Techniques: I: Condylectomy. II: Gap Arthroplasty. III: Interpositional Arthroplasty. 13

14. Management: Adult • Cause: • Cause: • Trauma • Aim: • R e s t or a t ion of s a t is f a c t o r y m o v e m e nt • Trauma •Infection • Aim : •Restoring function and movement • B o ny r e p l a c e m e n t w i t h CCG • C or r e c t i on o f o cc l u s a l a nd c o s m e t i c d e f o r m i ty Childhood 14

15. SURGICAL APPROACHES Blair inverted hockey stick vertical incision Dingman question mark Al-Kayat & Bramley in 1979- modified preauricular approach and Ivy in 1936- Thoma in 1958- angu l a t ed P rea u ric u la r i n ci s i on - Popowich and Crane in 1982- 15

16. Submandibular approach Postramal incision (Hinds) Endaural incision Coronal approach Postauricular approach 16

17. Condylectomy: A d vocated in cases of f ibrous ankylosi s , w h ere j oint space is obi l te r a ted with depos i t i on of f ib r ous bands but the r e is not m uch defor m i t y of c ondyl a r head. • Preauricular approach used commonly, others include Al Kayat Bramley, inverted hockey stick. 17

18. Gap Arthroplasty: • Section consists of two horizontal osteotomy cuts and removal of bony wedge for creation of a gap. • No substance is interposed between the two cut bony surfaces. • Minimum gap of 1 cm to prevent reankylosis. 18

19. Interpositional Arthroplasty: • Involves creation of a gap, but in addition a barrier is inserted between the cut bony surfaces to minimize risk of recurrence and to maintain vertical height of ramus. 18 19

20. 20

21. Materials used in Interpositional Arthroplasty: 21

22. KABAN’S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS 1. Early surgical intervention. 2. - Aggressive resection: Gap of at least 1 – 1.5 cm should be created. 3. - Ipsilateral coronoidectomy and temporalis myotomy: A f ter gap ar t hrop l as t y , co r onoid e cto m y on the sa m e side ca r r i ed out. should be - Temporalis muscle attachments are severed by carrying out temporalis myotomy. 4. Contralateral coronoidectomy and temporalis myotomy. 22

23. 5. Lining of glenoid fossa region with temporalis fascia. 6. Reconstruction of ramus with costochondral graft. 7. Early mobilization and aggressive physiotherapy for months postoperatively. at least six 8. Regular long term follow up. 9. To carry out cosmetic surgery at later date, when growth of patient is completed. 23

24. COMPLICATIONS DURING SURGERY During Anesthesia: a. As the patient cannot open the mouth, awake blind intubation has to be done where co – op e r a t i on is r eq u i r ed whi c h i s d i f ficu l t to a c h i eve so m et i m es. b. Because of small mandible and altered position of larynx, intubation poses a problem. c. Aspiration of blood clot, tooth or foreign body during extubation. d. Danger of falling back of tongue and obstructing airway is always there after extubation. 24

25. During Surgery: a. b. c. d. e. f. Hemorrhage. Damage Da m age Da m age Da m age Da m age to to to to to external auditory meatus. zygomatic and temporal auriculotemporal nerve. parotid gland. glenoid fossa. branch of facial nerve. During Postoperative Followup : a. b. c. Infection. Open bite. Recurrence of ankylosis. 25

26. FREY SYNDROME: 1 st   described by frey. It is localised gustatory sweating in the area supplied by auriculotemporal nerve. Cause: Congenital or acquired Surgery of parotid gland, TMJ , parotid abscess, facial wound. Clinical feature: Pain in area supplied by ATN Gustatory sweating Erythema & flushing Positive iodine starch test     1. 2. 3. 4. 26

27.  1. 2. 3. 4. 5. i. ii. iii. Treatment: Antiperspirants Anticholinergic prepn: glycopyrolate Botulinum toxin A inj. Radiation therapy: 50 Gy Surgical: Skin excision: for localise & small area ATN section: not permanent Tympanic neurectomy: safe procedure 27

28. RECURRENCE OF ANKYLOSIS Several factors said to be responsible: 1. 2. 3. Inadequate gap created between fragments. Fracture of costochondral graft. Loosening of cos t ochond r al gr a ft due to inadequa t e ra m us. Inadequate postoperative physiotherapy. Inadequate coverage of glenoid fossa surface. fixation to 4. 5. 6. Higher osteogenic potential and periosteal osteogenic responsible for high rate of recurrence in children. power maybe 28

29. THANK YOU! 29