TMJ Ankylosis.pptx

TMJ Ankylosis-Dr Stanley John

1. TMJ ANKYLOSIS DR. STANLEY JOHN CHERIYAN DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS INTRODUCTION SURGICAL ANATOMY ETIOLOGY PATHOGENESIS CLASSIFICATION MANAGEMENT COMPLICATIONS REFERENCES

3. INTRODUCTION ankylosis  is joining of bone resulting in immobility of a joint. Problems : Limited mouth opening and mastication Speech Facial growth asymmetries and mandibular deficiencies Airway compromise Dental care Psychological burden Reduced QOL

4. HISTORICAL PERSPECTIVES Burton in 1826 described the treatment of ankylosis by the formation of artificial joints Verneuil in 1826 was the first to do gap arthroplasty Humphry performed first condylectomy for ankylosis in 1854 In 1914, Murphy reported the use of autogenous graft as interposition material after lysis of TMJ ankylosis In 1942, Pickerill propounded that the ankylosed TMJ should be reconstructed by means of cartilage graft

5. Gordon in 1955 used alloplastic material to replace TMJ disc after discectomy. Georgiade first described the use of the dermis as a disc replacement in 1957. A uricular cartilage as a replacement for the disc was introduced by Perko in 1973. I n 199 K a ba n g a v e p r o t o c o l f o r the mana g em e n t o f ankylo s is w hic h w as modified in 2009. Wolford first used TMJ prosthesis in 1992

6. TMJ anatomy Synovial joint of condylar variety

7. TMJ anatomy Bony anatomy : Glenoid fossa Condyle

8. TMJ anatomy Muscles : Masseter Lateral pterygoid Medial pterygoid Temporalis

9. TMJ anatomy Ligaments : Lateral/Temporomandibular Stylomandibular Sphenomandibular Fibrous capsule

10. TMJ anatomy

11. TMJ anatomy

12. Facial nerve & TMJ Distance from the lower point of the external bony auditory canal to the bifurcation: 1.3 to 2.8 Posterior glenoid tubracle to the bifurcation: 2.4 to 3.5 cm The most variable measurement was the point at which the upper trunk crosses the zygomatic arch ranging from 0.8 to 3.5cm to the most anterior portion of the bony external auditory canal.

13. TMJ anatomy Anatomic Difference between adult and child TMJ Adults Children Thick Cortical bone Thin cortical bone Neck is thin Neck Is thick reason y condylar # is common Anterior wall of auditory meatus is composed of bone Anterior wall of auditory meatus is composed of cartilage Vestigeal , remnant in adults Presence of discomalleolar ligament

14. Etiology of Ankylosis Trauma At birth – forceps delivery Heamarthrosis (direct/indirect trauma) Condylar fracture –intracapsular/ extracapsular Glenoid fossa fracture ( rare ) Infections Otitis media Parotitis Furuncle Abscess around the joint Osteomyelitis of the jaw Actinomycosis

15. Inflammation Rheumatoid arthritis Osteoarthritis Septic arthritis – hematogenous spread Ankylosing spondylitis Rare causes Polyarthritis Measles Small pox Congenital AV Malformations Systemic causes Scarlet fever Typhoid Beriberi Bifid condyle Prolonged trismus Prolonged immobilization Idiopathic Burns Tumors Other Causes

16. Etiology of pseudoankylosis Depressed zygomatic arch Fracture dislocation of condyle Hypertrophy of coronoid process Fibrosis of temporalis muscle Myositis ossificans Scar contracture Tumour of condyle or coronoid

17. Pathogenesis Trauma to the joint Intracapsular Hemarthrosis formation and subsequent reorganization Prolonged immobilization Ossification Hypomobility

18. Pathogenesis Intracapsular hematoma ossification theory is based on animal studies / surgically created fracture Otzan et al proved that Intracapsular hematoma formation is not enough for ankylosis formation Goss et al : if the disk is left in place and undamaged , ankylosis didn’t occur Collection of blood , bone , cartilage fragments leads to environment favoring ankylosis

19. Pathogenesis Laskin(1978) : contact between articular surface of glenoid fossa and ramus was essential for ankylosis Rowe’s theory of burst condyle Condylar head in younger person is not well developed with wide neck and soft head Less adapted to crushing injuries directed along its long axis Leads to burst condyle and Intracapsular hematoma +bone fragments

20. Clinical manifestation and sequelae Decreased interincisal opening < 5 mm Inability to form oral seal Absent condylar movements Restricted mandibular growth Prominent antegonial notch Elongated coronoid Oral : Malocclusion Poor oral hygiene

21. Clinical manifestation and sequelae Unilateral cases : Chin deviation towards affected side Fullness on affected side , flattening on contralateral side Shortened vertical height Deepened antegonial notch Deviation to opposite side on opening

22. Clinical manifestation and sequelae Bilateral cases : Retrognathic mandible Microgenia Bird facies / Andy gump deformity Convex profile Short hyomental distance + tight suprahyoid musculature Absent / deficient cervicomental angle Open bite B/L posterior crossbite

23. Differential diagnosis : Depressed zygomatic arch fracture Adhesions of the coronoid process to zygoma Hypertrophy of the coronoid process Fibrosis of the temporalis muscle Myositis ossificans Scar contracture following thermal injury Tumor of the condyle or coronoid process

24. Radiographic assessment Panoramic radiograph : Hazy/complete bony obliteration of joint space Reduced vertical height of ramus Bulky coronoid Shallow sigmoid notch Lateral / anterior cephalogram : Shortened posterior facial height Steep occlusal and mandibular planes Retrognathia Retrogenia Airway narrowing

25. Radiographic assessment CT scan : Axial : mediolateral & anteroposterior extent proximity with skull base

26. Radiographic assessment CT scan : Coronal : Mushroom shaped head Mediolateral extent and level of inferior cut Proximity to maxillary artery Radiolucent area inside the ankylotic mass , represents remanescent disk

27. Radiographic assessment CT scan : 3D CT: Elongated coronoid process shallow sigmoid notch Reduced vertical height Accentuated antegonial notch Mandibular asymmetry

28. Classification Kanjanian classification : True ankylosis False ankylosis Pseudo ankylosis

29. Classification Topazian classification : Stage I: ankylotic bone limited to the condylar process Stage II: ankylotic bone extending to the sigmoid notch Stage III: ankylotic bone extending to the coronoid process.

30. Classification Sawhneys classification : Type I : Flattened and deformed head Dense fibrous adhesions Probably due to a communited condylar head fracture

31. Classification Sawhneys classification : Type II : Misshaped head Bony fusion of head to articular surface in small area Upper articular surface and articular disk undamaged Communited fracture of head + partial damage to upper articular surface

32. Classification Sawhneys classification : Type III: Bony block bridging ramus and Zygomatic arch Displaced head lying fused or free medially Severe fracture dislocation of head + laceration of capsular ligaments

33. Classification Sawhneys classification : Type IV: Wide and deep bony block extending from ramus to upper articular surface completely Complete loss of joint architecture Fracture dislocation of head + injury to capsular ligaments , articular disk , upper articular surface .

34. Classification Radiographic classification : Hakim and Metwali Type-I: uni / bilateral fibrous ankylosis Type-II: uni /bilateral bony fusion with maxillary artery at normal anatomic location and safe distance from ankylotic chunk Type III: maxillary artery in close proximity to the ankylotic chunk/ running through it Type IV: extensive ankylosis / fusion with skull base proximity to other vital structures- carotid, jugular foramina, foramen spinosum and pterygoid plates

35. Management Primary treatment goals : Resection of ankylosis and achieve normal mouth opening Restoration of function of TMJ Prevent reankylosis and Achieve symmetric mandibular / correct mandibular asymmetry

36. Management Challenges : Anesthetic challenges Reankylosis Restoration of growth centre Correction of esthetics

37. Management Approaches Pre-auricular Preauricular- hockey stick Al- kayat Bramley modification of pre-auricular Endaural Post-auricular Submandibular Rhytidectomy

38. Management Kaban’s protocol : Removal of the ankylotic chunk to create a gap of no less than 1.5 cm Ipsilateral coronoidectomy. After this resection the MIO Should be > 35 mm Contralateral coronoidectomy. Temporalis fascia flap and costochondral graft harvest. Rigid fixation of CCG MMF in prefabricated splint x 10 days Release of MMF and a strict protocol of physiotherapy

39. Management Modified Kaban’s protocol for pediatric patients : Aggressive excision of fibrous / bony mass Coronoidectomy on ipsilateral side Coronoidectomy on opposite side if step 1 and 2 do not result in MIO of > 35 mm or dislocation of opposite side Lining of joint with temporalis fascia or native disc Reconstruction of with DO or CCG and rigid fixation Early mobilization Aggressive physiotherapy

40. Management Treatment philosophies: Gap arthroplasty Interpositional arthroplasty TMJ Reconstruction

41. Gap arthroplasty Verneuil in 1826 was the first to do gap arthroplasty. The ankylotic mass is shaved to a flat ramus surface. If we find a cleavage line, it is used as the superior bony cut plane. If there is no cleavage line, an imaginary line through the lower border of the zygomatic arch is considered.

42. Advantages Simple procedure Short operating time Disadvantages Pseudo-articulation Short ramus height Failure to remove all bony disease Development of open bite Recurrent ankylosis (60%) .

43. Inter positional arthroplasty First introduced by Verneuil in 1860 I t min i mi z es r edu c tion in the v e r ti c a l heig h t o f r amus and r edu c es t he risk o f relapse and malocclusion

44. Interpositional materials Autogenous Allogenous Alloplastic Costochondral graft Chromatized submucosa of pig bladder Metallic- tantalum foil/ plate Metatarsal bone grafts Lyophilized bovine cartilage 316L stainless steel Sternoclavicular graft Titanium Auricular cartilage Gold Temporal fascia Nonmetallic Fascia lata Silastic Dermis of Temporalis muscle Teflon Acrylic Nylon Proplast Ceramic implants

45. Ideal requisites of interpositional materials Cost effective Cosmetic consequences of harvesting should be minimal Stable under masticatory force Minimal risk of infection Prevent recurrence caused by heterotrophic calcification

46. Disadvantages of interpositional materials Alloplastic materials Foreign body reaction Instability Infection Extrusion Autogenous materials All have some donor site morbidity Muscle flaps tend to contract and become fibrous Cartilage may calcify Thin grafts such as skin, dermis and auricular cartilage may not maintain the height of the ramus adequately, and may perforate under pressure from the condyle

47. Management Temporalis myofascial flap Inferiorly pedicled flap based on middle temporal and deep temporal artery Proximity Good blood supply Vague similarity to disc

48. Management Modification of temporalis flap : Fascia facing both surfaces Increased bulk Less open bite Less chance of temporalis muscle degeneration

49. An L-osteotomy is used to create the transport disc. The vertical limb of the “L” parallels the vector that will take the disc into the glenoid fossa. Th e s upe rior porti o n o f the dis c is r ounde d t o ma k e a n ew articular surface. A small portion of the osteotomy is left incomplete to stabilize the disc during placement of the distractor. The vascular attachments on the medial aspect of the disc are maintained. Distraction Osteogenesis for TMJ Reconstruction

50. A distractor length ranged between 13 and 30 mm is used. Attachment plates are chosen and trimmed according to the anatomy. At least 3 screws are placed in each plate. The dead space is filled with a fat graft (left) or temporalis flap, to inhibit heterotopic bone formation.

51. The distraction rod is brought through the skin of the neck through a separate stab incision. After a latency period of 7 days, distraction of 0.5 mm is carried out twice daily. Mobilization is begun immediately and maintained throughout distraction.

52. Af t er 3 mo n ths, the di s t r ac t o r is r e m o v ed t h r o u gh the sa m e submandibular incision. The superior attachment plate has moved far from the incision and is left in place. Callus i n the di s t r a ction g a p h a s f or m ed woven bone, which is remodelling into solid lamellar bone. Distraction is discontinued when the oc c lus i o n r e ac h es the des i r ed posit i o n . O v e r c or r ection m a y be used. The activation rod is removed or cut short below the skin. The distractor acts as a rigid fixator while c al l u s p r od u c es n e w b on e i n the distraction gap.

53. Advantage s Eliminates donor site morbidity Relapse rate is much less Early mobilization Disadvantages Additional operations might be necessary to correct any residual asymmetry after the end of growth Allows immediate mobilization of the jaw Duration is longer Patients compliance Device failure Infection

54. Sliding reconstruction of the condyle using posterior border of mandibular ramus in TMJ ankylosis Vertical osteotomy was performed on the proximal posterior border of the mandibular ramus till 1.0 cm above the angle and the osteotomized segment was moved up. The ipsilateral autogenous coronoid was implanted in the gap and fixed with titanium miniplates.

55. Th e b o n y b l oc k w as r es e c t ed and t he The bony block and prominent antegonial notch . glenoid fossa was recreated. Vertical osteotomy was performed on the entire posterior border of the mandibular ramus and then moved up. Fixation of the bone graft with titanium miniplates and resection of prominent antegonial notch.

56. Buccal fat pad Advantages Less chance of resorption Good long term interpositional material

57. Coronoid process In patients with ankylosis of the TMJ the coronoid is thicker than the normal one, so it can provide sufficient strength for loading of the TMJ after condylar replacement. Avoids a second surgical site and the related donor-site complications, which facilitated the operation and reduced the intervention. Less resorption

58. A: The coronoid process prepared for grafting. B: The use of native articular disc as an interpositional tissue ( arrow ). C: The fixation of coronoid process.

59. Fat Graft incision f o r ha r v e s t of (A ) Mar k ed pe riumbili c al abdominal fat graft. (B) Undermining of skin and fat before harvest. circumferential Composite harvest of abdominal fat. E xposu r e o f g r a f t si t e f o r augmentation of fat graft. (E) Adaptation of fat graft before closure

60. Indomethacin Indomethacin is a non-selective inhibitor of cyclooxygenase (COX) 1 and 2, enzymes that participate in prostaglandin synthesis from arachidonic acid. Indo m e tha c in i s use d mo s t c om m on l y f o r the t r e a t m e n t o f i n flamm a t ion and p ain r esu l t ing f r om rheumatic disease. Orthopaedic surgeons have been using Indomethacin to prevent the formation of heterotopic bone after hip replacement surgery. Studies have demonstrated that Indomethacin is a potent inhibitor of local remodelling and repair of bone after trauma. Initial results for the long term use of Indomethacin have been favourable, providing a solution for many patients however further research is warranted

61. TMJ RECONSTRUCTION Goals Restoration of normal joint function Restoration normal posterior vertical dimensions and length Stable skeletal occlusal relationship Maintenance of facial symmetry Lifetime maintenance of restored function, comfort and esthetics

62. Autogenous TMJ replacement 1909 – Bardenheur - replaced condyle - 4 th metatarsal 1920 - Gillies used costochondral graft Donor site alternatives Ramus condylar unit Glenoid fossa lining Costochondral graft Metatarsal graft Sternoclavicular joint graft Fibula graft Iliac graft Dermis graft Auricular cartilage graft Temporalis myofascial flap

63. RESECTED SEGMENT AS AUTOGRAFT R. Gunaseelan has used the resected segment as an autograft after recontouring , in extensive ankylosis of temporo mandiblular joint. The graft is rotated 90°s, so that the cortical surface faces the temporal bone 65

64. CCG

65. C C G Advantages: Most widely used Has a cartilage cap, mimicking both the bone and cartilaginous components Has intrinsic growth potential Easy accessibility and adaptation Gross anatomical similarity to the mandibular condyle Limitations: Unpredictable growth Poor bone quality Possible separation of cartilage from bone Donor-site complications: Pleural tear Pneumothorax Pleural effusion

66. Sternoclavicular Advantages Similar anatomical and physiological characteristics. Consists of a cartilaginous cap. Option for a whole joint graft. Has the potential for growth. Probability of regeneration at donor site Donor site compli c a tions: Damage to the great vessels. Instability of the clavicle under stress with resulting shoulder instability. Clavicle fracture.

67. Metatars a l Advantages: Combination of articular cartilage and bone. Fitting anatomy because of small size. Has potential for growth. Donor-site complications: Aesthetic loss of a toe. MTP joint being a simple hinge joint does not follow the same movements as the TMJ

68. Fib u la Advantages in sh a p e a n d d e ns ely Tubular c orti c a l . g r a f t h as b e tt er Vascularized survival rate. f o r la rg e More suitable mandibular defects Limitations Lacks articular cartilage Donor-site complications Ankle s t i f fness , i n s t ab i l i ty a nd weakness Numbness of the lateral side of the leg P e da l i s chaemia a n d f oot oedema

69. Iliac crest Advantages: Has a cartilage cap, mimicking both the bone and cartilaginous components. Has potential for growth More suitable for large mandibular defects Donor-site complications: Altered gait Poor scar Ilium fracture Peritonitis Retroperitoneal haematoma

70. Alloplastic joint replacements 1840– John Murray treated ankylosis - wood block 1890– Gluck - ivory prosthesis 1933 – Risdon – gold foil 1947 – Goodsell - titanium foil Total joint - Kent-Vitek prosthesis in 1970 Christensen – 1964 - lined glenoid fossa —vitallium Chase – 1995 - chromium cobalt head

71. Protocol for joint replacement Release the ankylosed joint. Remove the heterotopic and reactive bone with thorough debridement. Reconstruct the TMJ with a total joint prosthesis. Pack a fat graft around the articulation area of the prosthesis. Perform indicated orthognathic surgery in a single surgery .

72. Indications Ankylosed, degenerated or resorbed joints with severe anatomic discrepancies. Failed autogenous bone grafts. Recurrent ankylosis

73. Relative contraindications Patient age Lack of understanding of the patient Uncontrolled systemic disease Allergic to materials used in devices Active infection at implantation site

74. Advan t ages Physical therapy can begin immediately. No need for second donor site. Reduced surgical time. Alloplasts – mimic normal anatomic contours, better adapted to the bony surfaces. Stable occlusion post-operatively. Decreased hospital stay. Opportunity to manipulate prosthesis design to discourage heterotrophic bone formation

75. Disadvantages Cost of prosthesis Material wear and failure Long term stability Inability to follow patients growth Potential for severe giant cell reactions Fit limitations of stock prosthesis

76. Alloplastic TMJ prosthesis Fossa prosthesis Condylar prosthesis Total joint prosthesis Kent- Viket Synthes Delrin -Timesh Christensen Biomet Lorenz

77. Biomet Lorenz Prosthesis Th e mandibular c om p one n t is m anu f act u r ed f r o m C o - C r all o y wi t h a r ou g h e n e d titanium plasma coating on the host bone side of the ramal plate The condylar component is secured to the ramus with self retaining, cross drive 2.7- mm self-tapping bone screws made of titanium alloy The ramus of the mandibular component is currently manufactured in lengths of 45 mm, 50 mm, and 55 mm Th e f oss a c omp o ne n t is manu f actu r ed f r o m a spec i fi c g r ade o f ult r ahigh mol ec ular weight polyethylene called Arcom manufactured by Biomet. The fossa is fixed to the zygomatic arch with self-retaining, self tapping 2-mm screws

78. Lorenz Prosthesis

79. Kent-Vitek Total Prosthesis In the early 1970s Kent and colleagues developed a glenoid fossa prosthesis The original VK-1 fossa had an articulating surface composed of poly tetrafluoro ethylene (PTFE). The fossa was revised and called the VK-2 fossa, and its articulating surface was composed of ultra-high molecular - weight polyethylene (UHM-WPE) . The flange of the prosthesis was secured to the zygomatic arch with screws. The condylar prosthesis was constructed of chromium cobalt with a layer of Proplast on the inner surface of the ramal flange to encourage rapid ingrowth of both hard and soft tissues Complications included glenoid fossa resorption, especially in patients who had undergone ramal lengthening

80. Christensen The Christensen TMJ fossa eminence prosthesis (FEP) is designed to be used alone as a partial joint for treatment of Severe internal derangement Adhesions Disc perforation Ankylosis The condylar prosthesis is always used in conjunction with a FEP and constitutes a total joint replacement.

81. IPG results in a significant improvement in MIO and lower recurrence rate when compared to GA. IPG also shows a greater improvement in MIO and comparable recurrence rate when compared to CCG reconstruction. GA and CCG reconstruction have a comparable recurrence rate. CCJ provides greater MIO when compared to AJR, whereas AJR is superior to CCJ in reducing pain 83

82. Costochondral graft is preferred by surgeons, but distraction osteogenesis is slowly gaining popularity and may ultimately become the standard procedure. Tissue engineering is a budding field which has shown promising results in animal studies but has not been applied to humans. To date, there is no ideal autogenous graft for condylar reconstruction that satisfies the complex anatomy and the myriad of functions of a missing condyle. 84

83. Complications of TMJ surgery Intra op Hemorrhage Damage to external acoustic meatus Parotid gland fistula Damage to auriculotemporal nerve Damage to zygomatic and temporal branch of facial nerve

84. Post op Transient facial nerve weakness Infection Auriculotemporal nerve injury- Frey’s syndrome

85. Long term complication Partial graft resorption Loose hardware Facial scarring Condylar overgrowth Limited mouth opening Reankylosis

86. References : Maxillofacial surgery vol II : Peter ward booth Principles of oral and maxillofacial surgery : Peterson Ahmed; Conservative gap arthroplasty in temporomandibularankylosis not involving the sigmoid notch:a selected age group study; British Journal of Oral and Maxillofacial Surgery (2016) 1–6 Junli Ma et al; Interpositional arthroplasty versus reconstruction arthroplasty for tmj ankylosis: A systematic review and meta-analysis; J of Cranio-Maxillo-Facial Surgery 43 (2015) 1202e1207 Lokesh Babu et al; Is aggressive gap arthroplasty essential in the management of tmj ankylosis?—a prospective clinical study of 15 cases; BJOMS 51 (2013) 473–478