Tmj ankylosis overview

overview of TMJ ankylosis,
craniomandibular ankylosis, sequelae of temporomandibular joint disorders, functional derangement, aims of surgery and strategies of intervention with possible complications that may follow

1. CRANIOMANDIBULAR
JOINT(CMJ) ANKYLOSIS
Presenter: Dr Kiprop, Jonathan.
Supervisor: Dr Butt
University of Nairobi ISO 9001:2008 1 Certified http://www.uonbi.ac.ke

2. *CMJ anatomy overview
*Definition of CMJ ankylosis
*Etiology
*Classification
*Clinical presentation
*Management strategies
*Complications
*Current understanding…presentation of Prof Guthua
Presentation Outline
University of Nairobi ISO 9001:2008 2 Certified http://www.uonbi.ac.ke

3. *Bilateral diarthrosis – right & left function together
*Articular surface covered by fibrocartilage instead of
hyaline cartilage
*Only joint in human body to have a rigid end-point of
closure that of the teeth making occlusal contact.
*CMJ is last diarthrodial joints joint to start develop,
7th week in-utero.
*Structured like 2 joints. Has 2 synovial cavities
*Capable of the largest proportion of translation and
rotation.
Peculiarity of CMJ
University of Nairobi ISO 9001:2008 3 Certified http://www.uonbi.ac.ke

4. Anatomy of CMJ; Components
University of Nairobi ISO 9001:2008 4 Certified http://www.uonbi.ac.ke

5. *The articular surface lined by a layer of fibrocartilage.
Absorbs masticatory forces better than hyaline cartilage
Superior reparative process.
*Articular disc attached to the fibrous capsule at the
peripheries
*The articular disc maximizes the congruency within
the CMJ to reduce contact pressure
Cont…
University of Nairobi ISO 9001:2008 5 Certified http://www.uonbi.ac.ke

6. *Fibrous capsule
The capsule is relatively firm medially and laterally ,
providing stability to the joint during lateral movements
during mastication.
capsule is relatively lax anteriorly and posteriorly,
allowing the condyle and disc to translate forward when
the mouth is opened.
*Lateral ligament(temporomandibular ligament)
Primary lig. Has oblique and horizontal fibres)
*Accessory ligs..spheno and stylomandibular ligs.
Located medial to the joint capsule. Suspend the
mandible to the cranium
Cont…
University of Nairobi ISO 9001:2008 6 Certified http://www.uonbi.ac.ke

7. University of Nairobi ISO 9001:2008 7 Certified http://www.uonbi.ac.ke

8. *Stability factors
Static..
Dynamic
*Movements …produced by attachments of muscles
of mastication
Protrusion and retraction
Elevation and depression
Lateral excursions
University of Nairobi ISO 9001:2008 8 Certified http://www.uonbi.ac.ke
Athrokinematics of CMJ

9. * Rotational movement
Mandibular condyle rolls relative to the inferior surface
of the disc.
Happens in the lower joint compartment
*Translational movement
Mandibular condyle and disc slide essentially together.
The disc usually moves in the direction of the translating
condyle.
The upper joint compartment
Athrokinematics of CMJ
University of Nairobi ISO 9001:2008 9 Certified http://www.uonbi.ac.ke

10. *Early phase, constituting the first 35% to 50% of the 
range of motion
involves primarily rotation of the mandible relative to 
the cranium
*Late phase - 50% to 65% of the total range of motion.
 Is marked by a gradual transition from primary rotation 
to primary translation
Athrokinematics of CMJ
University of Nairobi ISO 9001:2008 10 Certified http://www.uonbi.ac.ke

11. Athrokinematics of CMJ
University of Nairobi ISO 9001:2008 11 Certified http://www.uonbi.ac.ke

12. University of Nairobi ISO 9001:2008 12 Certified http://www.uonbi.ac.ke

13. *Greek terminology meaning ‘stiff joint’
*Inability to open the mouth either due to fibrous or 
bony union of the head of condyle and the glenoid 
fossa.
*Results in Hypomobility or immobility
*Jaw functions get affected
*Downward trend in the west but incidence still high in 
India and Africa 
CMJ Ankylosis 
University of Nairobi ISO 9001:2008 13 Certified http://www.uonbi.ac.ke

14. Classification of Ankylosis 
University of Nairobi ISO 9001:2008 14 Certified http://www.uonbi.ac.ke

15. Grading of CMJ ankyloses 
University of Nairobi ISO 9001:2008 15 Certified http://www.uonbi.ac.ke

16. University of Nairobi ISO 9001:2008 16 Certified http://www.uonbi.ac.ke

17. *Restricted mouth opening…trismus
*Facial asymmetry esp. in unilateral ankylosis. Bilateral 
maybe deceptively symmetrical 
*Mandibular micrognathia
*Bird face deformity, bird’s beak deformity. 
*Poor oral hygiene and rampant caries
*Absence of condylar movements
*Malocclusion esp. class 2 with posterior cross bite and 
anterior open bite.
Clinical Features 
University of Nairobi ISO 9001:2008 17 Certified http://www.uonbi.ac.ke

18. • Fusion of joint …mushroom deformity 
• Loss of joint space 
• Prominent antegonial notch 
• Coronoid hyperplasia
Radiographic features
University of Nairobi ISO 9001:2008 18 Certified http://www.uonbi.ac.ke

19. * Facial growth distortion… Aesthetics
* Nutritional impairment
* Respiratory disorders
* Malocclusion
* Poor oral hygiene
* Multiple carious and impacted teeth
Sequelae of CMJ Ankylosis
University of Nairobi ISO 9001:2008 19 Certified http://www.uonbi.ac.ke

20. *Release ankylosed mass and creation of a gap
*Creation of functional joint (improve patient’s oral
hygiene, nutrition and good speech)
*To reconstruct the joint and restore the vertical
height of the ramus
*To prevent recurrence
*To restore normal facial growth pattern
Aims of Management
University of Nairobi ISO 9001:2008 20 Certified http://www.uonbi.ac.ke

21. Principles of Management
University of Nairobi ISO 9001:2008 21 Certified http://www.uonbi.ac.ke
*Early surgical intervention
*Elaborate resection
*Early mobilization
*Aggressive physiotherapy for at least 6 months post
operatively

22. *Ipsilateral coronoidectomy and contralateral
coronoidectomy for longstanding ipsilateral CMJ
ankylosis
*Psychological rehabilitation
Principles of Management
University of Nairobi ISO 9001:2008 22 Certified http://www.uonbi.ac.ke

23. * Non-surgical management vs Surgical treatment
* Surgical Management
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty
4. Total joint reconstruction
Management Strategies
University of Nairobi ISO 9001:2008 23 Certified http://www.uonbi.ac.ke

24. •Fibrous ankyloses
•Pre-auricular incision is made
•Cut at the level of the condylar neck
•The head (condyle) should be separated from the
superior attachment carefully
•The wound is then sutured in layers
•The usual complication of this procedure is an
ipsilateral deviation to the affected side and anterior
open bite if the procedure was bilaterally.
Condylectomy
University of Nairobi ISO 9001:2008 24 Certified http://www.uonbi.ac.ke

25. * Extensive bony ankylosis.
* Consists of two horizontal osteotomy cuts
*Removal of bony wedges for creation of a gap
between the roof of the glenoid fossa and the ramus
of the mandible.
* This gap permits mobility
*Minimum gap should be 1cm to avoid re-ankylosis
Gap Arthroplastry
University of Nairobi ISO 9001:2008 25 Certified http://www.uonbi.ac.ke

26. * Improvement/modification on gap arthroplasty
* Currently the surgical protocol of choice
*Involves the creation of gap, with a barrier is inserted
between the two surfaces to avoid re-occurrence and
to maintain the vertical height of the ramus
Interpositional Arthroplasty
University of Nairobi ISO 9001:2008 26 Certified http://www.uonbi.ac.ke

27. University of Nairobi ISO 9001:2008 27 Certified http://www.uonbi.ac.ke

28. *Re-ankylosis
*Resorption
*Overgrowth
*Fracture
*Pain
Post-op. Complications
University of Nairobi ISO 9001:2008 28 Certified http://www.uonbi.ac.ke

29. *Inadequate gap btw fragments
*Inadequate coverage of glenoid fossa
*Inadequate post-op physiotherapy
*Fracture of costochondral graft
*High osteogenic potential and periosteal osteogenic
power responsible for high recurrence in children
Recurrence of CMJ Ankylosis
University of Nairobi ISO 9001:2008 29 Certified http://www.uonbi.ac.ke

30. *The results of the meta-analysis showed that IPG
results in a significant improvement in MIO and lower
recurrence rate when compared to GA.
* IPG showed a greater improvement in MIO and
comparable recurrence rate when compared to CCG
reconstruction.
*GA and CCG reconstruction had a comparable
recurrence rate.
*CCJ provides greater MIO when compared to AJR,
whereas AJR was superior to CCJ in reducing pain.
Al-moraissi ea et al. A systematic review and meta-analysis of the clinical outcomes for various surgical modalities in the
management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg. 2015 apr;44(4):470-82.
Studies
University of Nairobi ISO 9001:2008 30 Certified http://www.uonbi.ac.ke

31. *17 studies with 740 participants were included in the
final analysis. The IPG therapy showed a significantly
greater MIO when compared to GA.
*The analysis showed that IPG was more effective and
displayed a lower recurrence rate, followed by AR and
GA, in treating CMJ ankylosis.
*Analysis provides strong evidence supporting IPG as a
first-line therapy for CMJ ankylosis.
Liu x et al. (2015) effectiveness of different surgical modalities in the management of temporomandibular joint
ankylosis: a meta-analysis. Article · Literature Review inInternational Journal of Clinical and Experimental
 
Medicine 2015 Nov. 15;8(11):19831-9.
Studies
University of Nairobi ISO 9001:2008 31 Certified http://www.uonbi.ac.ke

32. *Retrospective study evaluated the cause of CMJ
ankylosis and the 36-month postoperative results of
gap arthroplasty in 50 patients (62 joints).
* Result. Trauma to the CMJ was documented as a
major etiologic factor in 86% of cases.
*The recurrence rate was 2%.
* The long-term functional results of gap arthroplasty
are satisfactory and comparable to other modalities
*Postoperative exercises play a crucial role in lasting
success.
Roychoudhury et al. Functional restoration by gap arthroplasty in temporomandibular joint ankyloses.Oral surg oral med
oral pathol oral radiol endod 1999;87:166-9
Studies
University of Nairobi ISO 9001:2008 32 Certified http://www.uonbi.ac.ke

33. 1.Mérida-velasco JR et al. Development of the human temporomandibular joint. The anatomical record.1999
may 1;255(1):20-33.
2.Akama, M.K., Guthua, S., Chindia, M.L., Kahuho, S.K. Management of bilateral temporomandibular joint
ankylosis in children: case report. East Afr Med J. 2009;86:45–48.
3.Illustrated dental embryology, histology, and anatomy, bath-balogh and fehrenbach, 2011, page 266.
4.Malik, N.A. Textbook of oral and maxillofacial surgery. Jaypee Brothers Medical Publishers Ltd, New
Delhi; 2002:207–218.
5.Roychoudhury et al. Functional restoration by gap arthroplasty in temporomandibular joint ankyloses.Oral
surg oral med oral pathol oral radiol endod 1999;87:166-9
6.Xiang g et al. (2014) A retrospective study of temporomandibular joint ankylosis secondary to surgical
treatment of mandibular condylar fractures. Br J oral maxillofac surg 52: 270-274.
7.Madhumati.S. et al. CMJ ankylosis: management with reconstruction and interpositional arthroplasty. Int J
Oral Maxillofac Surg. 2015 oct-dec;24(4):374-9.
8.Khadka, A., Hu, J. Autogenous grafts for condylar reconstruction in treatment of CMJ ankylosis: current
concepts and considerations for the future. Int J Oral Maxillofac Surg. 2012;41:94–102.
9.Al-moraissi ea et al. A systematic review and meta-analysis of the clinical outcomes for various surgical
modalities in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg. 2015
apr;44(4):470-82.
10.Liu x et al. (2015) Effectiveness of different surgical modalities in the management of temporomandibular
joint ankylosis: a meta-analysis. Article · Literature Review inInternational Journal of Clinical and
 
Experimental Medicine 2015 Nov. 15;8(11):19831-9.
11.Https://clinicalgate.Com
References and Bibliography
University of Nairobi ISO 9001:2008 33 Certified http://www.uonbi.ac.ke

34. University of Nairobi ISO 9001:2008 34 Certified http://www.uonbi.ac.ke
Thank you.