Trismus

Trismus

1. SEMINAR BY TEJASWINI PSS TRISMUS & TMJ ANKYLOSIS

2. Contents : Trismus Etiology of trismus TMJ ankylosis Etiology of TMJ ankylosis Classification Clinical manifestations Sequlae Management of TMJ ankylosis Conservative Surgical

3. Trismus “inability to open the mouth “

4. What is Normal Opening of the Mouth ? 40– 60 mm varies from patient to patient lower limit at 35 mm. gender may be a factor in vertical mandibular opening ? In general, males display greater mouth opening

5. Etiology

6. TRISMUS RELATED TO DENTAL PROCEDURES

7. Following extraction of teeth inflammation involving the muscles of mastication or direct trauma to the TMJ 2–5 days after a mandibular block medial pterygoid muscle is accidentally penetrated or A vessel is punctured - small bleed  haematoma  organize  fibrosis

8. INFECTIONS

9. INFECTIONS – TRISMUS The hallmark of a masticatory space infection odontogenic or non- odontogenic nature Odontogenic infections - 3 major origins: pulpal, periodontal and pericoronal if unchecked  can spread to various facial spaces of the head and neck and  serious complications such as cervical cellulitis or mediastinitis

10. Non- odontogenic infections : tonsillitis, tetanus, meningitis, Parotid abscess and brain abscess

11. TRAUMA - TRISMUS

12. Mandible fractures – common accidental incorporation of foreign bodies because of external traumatic injury. trauma of the zygomatic arch and zygomaticomaxillary complex (ZMC), which interferes with the movement of the coronoid process

13. Etiology of Temporomandibular Joint Ankylosis Secondary to Condylar Fractures : The Role of Concomitant Mandibular Fractures Dongmei He, DDS, MD, PhD,* Edward Ellis III, DDS, Yi Zhang, DDS, MD, PhD‡ J Oral Maxillofac Surg 66:77-84, 2008

14. the association between condylar fractures and temporomandibular joint (TMJ) ankylosis C ombination of intracapsular fracture concomitant widening of the mandible leads to the lateral pole of the condyle or the condylar stump to become displaced laterally or superolaterally in relation to the zygomatic arch, where it fuses.

15. TUMOURS AND MALIGNANCIES…

16. Tumours and Oral Malignancies risk of misdiagnosing Thorough clinical and radiographic examination to rule out neoplastic disease primary or metastatic, in the epipharyngeal region, parotid gland, jaws or TMJ Oral submucous fibrosis - precancerous condition

17. DRUG THERAPY

18. Drug Therapy Some drugs cause trismus as a secondary effect succinyl choline phenothiazines and Tricyclic antidepressants Trismus can be seen as an extrapyramidal side-effect of : metaclopramide , phenothiazines and other medications.

19. RADIOTHERAPY & CHEMOTHERAPY

20. Radiotherapy / Chemotherapy Radiotherapy is commonly used to treat squamous cell carcinoma of the head and neck and regional lymphomas muscles of mastication within the field of radiation  fibrosis  trismus Ischaemia caused by endarteritis obliterans Trismus complicates post-radiation dental care HOW TO MINIMIZE THESE ILL-EFFECTS ? protective stents, jaw exercises and hyperbaric oxygen to increase neovascularization.

21. Congenital / Developmental Causes trismus as a result of hypertrophy of the coronoid process causing interference of the coronoids against the anteromedial margin of the zygomatic arch . Trismuspseudo - camptodactyly syndrome

22. Miscellaneous Causes Other rare causes of trismus are: hysteria (psychogenic); lupus erythematosus

23. TMDs may be divided into extracapsular (mainly myofascial ) and intracapsular problems (including disc displacement, arthritis, fibrosis, etc )

24. TMJ ANKYLOSIS…

25. Ankylosis , or Anchylosis ( Greek –bent / crooked ) Ankylosis is a stiffness of a joint, as a result of injury or disease and results in hypomobiliy or no mobility.

26. When the structures outside the joint are involved, it is termed " false ankylosis ” . in contrast when the disease involves the TMJ itself, it is called " true ankylosis ”. When inflammation causes the joint-ends of the bones to be fused together the ankylosis is termed “ osseous” or complete

27. CLASSIFICATION OF ANKYLOSIS

28. Sawhney (1986 ) classification : Type I : The condylar head is present without much distortion . Management of Temporomandibular Joint Ankylosis Reza Movahed , DMD Oral Maxillofacial Surg Clin N Am 27 (2015) 27–35

29. Type II: Bony fusion of the misshaped head and the articular surface. No involvement of the sigmoid notch and coronoid process.

30. Type III: A bony block bridging across the ramus and the zygomatic arch. Medially an atropic dislocated fragment of the former head of the condyle is still found. Elongation of the coronoid process seen.

31. Type IV: The normal anatomy of the TMJ is totally destroyed by complete bony block between ramus and skull base.

32. ETIOPATHOLOGY OF TMJ FALSE ANKYLOSIS

33. False ankylosis results from pathological condition outside the joint and leads to limited mandibular mobility. CAUSES OF FALSE ANKYLOSIS MUSCULAR TRISMUS pericoronitis , submasseteric , pterygomandibular , infra - temporal or submandibular spaces infection

34. MUSCULAR FIBROSIS Muscular fibrosis from any long standing dysfunction like arthritis and myositis. MYOSITIS OSSIFICANS When there is progressive ossification after injury and hematoma formation especially of the masseter muscle, inability to open the mouth develops. This can be confirmed radiologically as well

35. TETANY When there is hypocalcaemia, the spasms in the muscles are produced hampering the opening of the mouth. TETANUS Acute infectious disease caused by Clostridium tetani is represented by an early symptom of lock-jaw because of persistent tonic spasm of the muscles

36. NEUROGENIC CAUSES Neurogenic causes like epilepsy, brain tumour and embolic hemorrhage in medulla oblongata are also represented by hypomobility of the jaw. TRISMUS HYSTERICUS • It is disease of psychogenic origin. DRUG INDUCED SPASMS • Drug induced spasms like in drug poisoning

37. MECHANICAL BLOCKADE Mechanical blockade on account of osteoma or elongation of the coronoid process of the mandible there by reducing it's movement under the zygomatic arch. FRACTURE OF THE ZYGOMATIC ARCH • Fracture of the zygomatic arch with inward buckling. FRACTURE OF THE MANDIBLE • Trauma causing fracture of the mandible leads to reflex spasm of the muscles and hence trismus

38. SCARS AND BURNS OF THE FACE Scars and burns of the face also, restrict the movements of the jaw. Post irradiation fibrosis lead to hypomobility of the mandible. CLEFT PALATE OPERATIONS can produce fibrosis of the pterygomandibular raphe and, consequently, limitation of mouth opening

39. ETIOPATHOLOGY of true ankylosis

40. Birth Trauma • Birth trauma producing so-called congenital ankylosis and occurs in cases of difficult delivery, particularly forceps delivery • At times, other bones are fractured as well. • The injury of the jaw caused by the use of forceps may not be discovered until later when it is noticed that the child could open his jaw only slightly.

41. Haemarthrosis Haemarthrosis is another cause of ankylosis . It is generally, due to fracture of the base of skull extending through the mandibular fossa - may also be caused by an intracapsular injury.

42. Cortical bone in a child is very thin - as a result of intracapsular fracture of TMJ, bleeding takes place within the joint – known as hemarthrosis The hematoma within the joint organises slowly which is then converted to fibrous tissue and then bone resulting in bony ankylosis

43. Suppurative arthritis • Suppurative arthritis, may be due to infection of the ear or mastoiditis or it may be of hematogenous origin leading to ankylosi

44. Rheumatoid arthritis • Rheumatoid arthritis, may cause great limitation of motion or complete ankylosis • There is associated atrophy of the muscles generally accompaning ankylosis , if contracted early in life.

45. Osteomyelitis Osteomyelitis affecting the mandibular condyle without involving the joint itself frequently results in limitation of motion + muscular trismus + peri -articular swelling, and suppuration often results in fistula formation

46. Fracture of the condyle especially comminuted fractures of the head of the condyle, may cause ankylosis . Trauma to the condyle in children is more likely to cause ankylosis than adults

47. Clinical manifestations vary according to: (a) Severity of ankylosis , (b) Time of onset of ankylosis , (c) Duration.

48. Early joint involvement - less than 15 years: Severe facial deformity and loss of function. 2. Later joint involvement after the age of 15 years : Facial deformity marginal or nil. But, functional loss severe. Those patients in whom the ankylosis develops after full growth completion have no facial deformity

49. CLINICAL MANIFESTATIONS

50. • Pain Healed chin laceration Reduced interincisal mouth opening or No mouth opening at all neglected oral hygiene impacted / malposed /carious teeth. • Inability to open the jaw and difficulty or inability to masticate food

51. UNILATERAL ANKYLOSIS : 1. Facial asymmetry with affected side appearing normal & the opposite side appearing flat. 2. Chin deviated to the ankylosed side. 3. Ante- gonial notch on the affected side 4 . Minimal condylar movements on palpation. 5 . Class II malocclusion on affected side and cross bite may be seen

52. underdevelopment of the mandible and is associated with a prominent angle of the jaw and curve of the inferior border called ‘ ante - gonial notching ’.  denotes an attempt at bending the bone by the powerful depressor muscles attached to the symphysis, which come into function when great force is needed to open the jaw

53. In BILATERAL ANKYLOSIS 1. Bird face deformity + micro gnathic mandible 2. Inability to open mouth + inability to masticate Class II malocclusion 3 . Deep ante - gonial notching 4 . Poor oral hygiene 5 . Severe malocclusion with crowding + protrusive upper anterior teeth + anterior open bite

54. In cases in which the disease was contracted early in life, a so-called “ bird face ‟ results. - a receding chin, - malocclusion and - impaction of teeth. The maxilla may be narrow and protrude

55. PROBLEMS ASSOCIATED WITH ANKYLOSIS

56. 1. Interferes with the mastication of food and with nutrition 2. Prevents oral hygiene and prophylactic care, and treatment of dental caries There is destruction of the growth center [situated in the condyle] and with absence of functional stimulation prevents normal development of the jaw  prevents normal eruption of the teeth and causes micrognathia

57. Diagnosis

58. 1. History of infection or trauma (birth trauma + falls + previous infection of the ear) 2. Findings at clinical examination (reduced interincisal opening + diminished/no TMJ movements + scar on the chin due to trauma) 3. Radiological findings

59. Radiographic Examination

60. Orthopantomograph : OPG will show both the joints for comparision – important in unilateral cases –will also reveal ante- gonial notching. • PA view will show the mediolateral extent of the bony mass – also reveal any mandibular asymmetry. • Lateral oblique – will demonstrate the anteroposterior extent of the bony mass and the elongation of the coronoid process

61. CT Scan/3D CT Scan – gives relationship to the middle cranial fossa and internal carotid artery (carotid canal) medially to the ankylotic mass – usually not seen in conventional radiographs. 3D CT SCAN showing Bony Ankylosis Coronal CT Scan showing Bilateral TM Joint Ankylosis

62. Radiographic changes are of extreme value in diagnosis In fibrous ankylosis 1.evidence of destructive + proliferative changes seen in bony compartments of TMJ + 2.haziness or narrowing of joint space In bony ankylosis - overall obliteration of joint space. - antegonial notching anterior to the angle of mandible - elongation of coronoid process

63. Imaging of temporomandibular joint ankylosis . A new radiographic classification- IE El-Hakim Dentomaxillofacial Radiology (2002) 31, 19 ± 23 Coronal CT showing bony exostoses in the glenoid fossa superiorly as well as medial on the condylar head, resulting in bony ankylosis

64. 3D CT of an ankylosed joint with an elongated coronoid process (c) that projects clearly under the zygomatic arch (z)

65. Post-contrast coronal CT scan of an ankylosed joint showing its relationship to the maxillary artery (M)

66. Axial (a) and coronal (b) CT scans of an ankylosed joint showing an elongated lateral pterygoid plate (P) which appears fused to the bony exostosis

67. What Happens If Ankylosis Is Left Untreated..

68. Normal growth & development of face is affected Nutritional impairment Speech impairment Sleep apnoea ( tongue falls back in sleep) in Bilateral Ankylosis . Malocclusion Poor and neglected oral hygiene Multiple carious and impacted teeth

69. MANAGEMENT OF ANKYLOSIS

70. CONSERVATIVE THERAPY ANKYLOSIS OF THE TMJ V.H.KAZANJIAN DMD, MD SURGERY, GYNECOLOGY OBSTETRICS, SEPTEMBER 1938, VOL 36

71. Treatment of Ankylosis is Surgical & should be corrected at the earliest  TO ENSURE EFFECTIVE FUNCTION AND GROWTH Surgical treatment options will depend on: 1. Age of onset of ankylosis 2. Whether unilateral or bilateral ankylosis 3. Extent of ankylosis and 4. Any associated facial deformity

72. Aims and Objectives of Surgery

73. 1. Release of ankylosed mass and creation of a gap to mobilize the joint. 2. Creation of a functional joint . 3. To reconstruct the joint and restore the vertical height of the ramus. 4. To prevent recurrence . 5. To restore normal facial growth pattern. 6. To improve esthetics and rehabilitate the patient (cosmetic surgery may be carried out at a later date or at second phase)

74. Surgical Approaches to the TMJ 1. Preauricular incision with modifications 2 . Submandibular incision 3 . Post auricular 4 . Post ramal 5 . Endaural incision 6 . Coronal incision

75. APPROACHES TO TMJ

76. TIMING OF SURGERY

77. Surgery for Ankylosis can be done in 2 stages : • In the first stage surgery - release of ankylosis to bring about jaw mobility and growth. • In the second stage surgery an orthognathic surgery can be planned to restore facial esthetics. • single stage procedure where release of ankylosis and esthetic correction are done in a single stage in adults or after cessation of growth spurts in children

78. TYPES OF SURGICAL PROCEDURES

79. 1. Condylectomy 2 . Gap arthroplasty 3 . Interpositional Arthroplasty . 4 . Ramus Osteotomy 5 . Angle’s Osteotomy

80. Use of Brisement Force • The forced opening of the jaw with the patient under general anesthesia is the oldest method that has been employed. • The jaw is forced open by means of a mouth gag and mobilized as much as possible by forceful manipulation. • In FIBROUS ANKYLOSIS or immobility caused by muscle spasms or fibrosis, this method may yield good results. • After the jaw has been mobilized, the patient is further benefited by exercises

81. Condylectomy and Arthroplasty • In both condylectomy and osteoarthrotomy the condyle is removed. • The two methods do not differ a great deal, except for the amount of bone excised. • In a condylectomy the condyle is detached and removed , whereas an osteoarthrotomy includes the excision of the entire joint and / or an adequate amount of bone below the joint

82. Condylectomy Condylectomy consists of excision of the condyle. Indications : 1.severe arthrosis , 2.various types of arthritis, 3.in malunited condylar fractures with limitation of motion and pain during mastication. 4. cases of fibrous ankylosis where the articular space has not been completely eliminated.

83. Complications / Disadvantages of Condylectomy Loss of vertical height of the ramus. In case of bilateral condylectomy , it may create an anterior open bite. In unilateral cases, there may be deviation of the jaw on opening

84. Osteoarthrotomy (Gap Arthoplasty ) • In bony ankylosis - the condyle is completely fused to the base of the skull - the coronoid is small size, often elongated • Because the joint is completely eliminated by the disease, or bony mass - an osteoarthrotomy or a double osteotomy is performed to remove a slice of bone, which is known as gap arthroplasty ‟. • In gap arthroplasty , a piece of bone about 1.5 to 2 cm in width is removed. • tendency for ankylosis to recur, some autogenous / alloplastic material interposed between cut bony ends

85. The mouth is forced open with the help of a mouth gag to check the mouth opening -a gap of 1.5 - 2 cms is created & not interposed with any material. • Post-op, this gap is maintained by active physiotherapy to prevent re- ankylosis . • When adequate movement and mouth opening cannot be achieved, it may be necessary to osteotomise the coronoid process also.

86. Interpositional Arthroplasty • similar to the gap arthroplasty . Placing a interpositional material between the two bony cut ends avoids contact between them and thus minimises chances of re- ankylosis

87. Various interpositional materials have been used which can be either alloplastic materials or autogenous . • ALLOPLASTIC MATERIALS such as silastic , acrylic Another excellent material is Teflon such as is used for vascular grafts. • AUTOGENOUS MATERIALS such as temporalis muscle, temporalis fascia, skin grafts, auricular cartilage, fascia lata etc ; have been attempted

88. CORONOIDECTOMY • In most of these cases there is always an elongated coronoid process. • Ipsilateral coronoidectomy and temporalis myotomy

89. After carrying out gap arthroplasty , coronoidectomy on the same side should be carried out either separately or in combination with the gap arthroplasty from the same extra-oral incision. • The coronoid process is cut at the level of sigmoid notch till the anterior border of the ramus + the temporalis muscle attachments are severed by carrying out temporalis myotomy

90. The interincisal opening > 35 mm  then there is no need to carry out contralateral coronoidectomy . • maximum inter- incisal opening < 35 mm  coronoidectomy + temporalis myotomy on the uninvolved side Lining of the glenoid fossa is done with temporalis muscle / fascia.

91. RAMUS OSTEOTOMY : An operation in which osteotomy of ramus is done and a pully like structure is inserted between the fragments. ANGLES OSTEOTOMY : Angle osteotomy in which masseter and medial pterygoid muscle are interposed between the fragment to prevent relapse

92. KABAN’S PROTOCOL Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

93. Aggressive excision of fibrous and/or bony mass Coronoidectomy on affected side Coronoidectomy on opposite si de if steps 1 and 2 do not result in MIO of 35 mm or to point of dislocation of opposite side Lining of joint with temporalis fascia or the native disc, if it can be salvaged

94. 5. Reconstruction of RCU with either DO or CCG and rigid fixation 6. Early mobilization of jaw ; if DO used to reconstruct RCU, mobilize day of surgery; if CCG used, early mobilization with minimal intermaxillary fixation (not >10 days) 7. Aggressive physiotherapy

95. USE OF COSTOCHONDRAL GRAFT • In children, after the release of the ankylosis . it is necessary to place a material that will allow growth to occur. • A costochondral graft is harvested from the 5th 6th or 7th rib. •A costo-chondral junction of about 1.5 cm is harvested and attached to the lateral surface of the ramus of the mandible to reconstruct the ramus.  functional and anatomical joint is created. • Cosmetic surgery is carried out at the later date when the growth of the patient is completed

96. Temporalis flap outlined (malachite green), B , dissected, and 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. Kaban , Bouchard, and Troulis . Management of Pediatric TMJ Ankylosis . J Oral Maxillofac Surg 2009.

97. Complications of costochondral grafting procedure 1 . Second surgical site 2 . Donor site complications such as pleuritic pain, pneumothorax 3 . Excessive growth of the graft beyond what is required. This can be minimised by taking not more than 1.5 cm of costochondral graft.

98. Aftercare After arthroplasty , especially gap arthroplasty , patient requires a splint inserted at the time of operation to prevent scar contracture Scar formation - tendency to pull the ramus up, which causes malocclusion and cross-bite The use of a splint  raise the bite  increases the gap between the bone edges  so that after the healing is complete there is a slack which allows the patient to bring the teeth into occlusion when the splint is removed and permits free opening of the jaw. In unilateral cases it is also important to guide the jaw into normal position by means of a guide plane

99. PHYSIOTHERAPY

100. Postoperative Physiotherapy Physiotherapy is as important as the surgery itself…. • active exercises of the jaws as soon as it can be tolerated . • Pressure with finger or simple finger exercises to gently force the mouth open initially; ice cream sticks / tongue blades / acrylic screw / jaw exerciser . • A mouth gag can be used for forceful mouth opening at a later stage.

101. COMPLICATIONS DURING TM JOINT ANKYLOSIS SURGERY

102. DURING ANAESTHESIA

103. 1.As the patient cannot open the mouth, awake blind intubation has to be done, especially where patients cooperation is required, which is very difficult to obtain from younger patients. 2.Because of small mandible and altered position of the larynx, intubation poses a problem 3.Aspiration of blood clot , tooth or foreign body during extubation as throat cannot be packed prior to surgery. 4.Danger of falling back of tongue and obstructing airway is always after extubation

104. DURING SURGERY

105. DURING SURGERY • Hemorrhage due to damage to any of the superficial temporal vessels, transverse facial artery, inferior alveolar vessel and internal maxillary vessels, pterygoid plexus of veins. • Damage to external auditory meatus. • Damage to zygomatic and temporal branch of facial nerve. • Damage to glenoid fossa and thus perforation into middle cranial fossa. • Damage to auriculotemporal nerve. • Damage to parotid gland. • Damage to the teeth during opening of the jaws with 72 jaw stretcher / mouth gag.

106. DURING POSTOPERATIVE FOLLOW-UP 1.Infection 2.Open bite 3.Recurrence of ankylosis

107. Three factors, namely: 1.Creation of a gap of sufficient width ( 1.5 -2 cm) 2.Careful application & stabilization of suitable interpositional medium that completely covers the surfaces of sectioned bone 3.Jaw exercises done sincerely over a period of several years

108. Review of literature

109. A Protocol for Management of Temporomandibular Joint Ankylosis in Children Leonard B. Kaban , DMD, MD,* Carl Bouchard, DMD, MSc, FRCD(C),† and Maria J. Troulis, DDS, MSc‡ J Oral Maxillofac Surg 67:1966-1978, 2009 Ten-year-old girl with left TMJ ankylosis secondary to local infection (otitis media). A, Frontal photograph demonstrating maximal mouth opening of 0 mm. B, Three-dimensional computed tomographic scan reconstruction demonstrating bony ankylosis between condyle and cranial base and coronoid hyperplasia.

110. New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients N. N. Andrade, R. Kalra , S. P. Shetye : New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients. Int. J. Oral Maxillofac . Surg . 2012; 41: 1495–1500.

111. management of patients with the triad of temporomandibular joint (TMJ) ankylosis , micrognathia and obstructive sleep apnea syndrome new surgical protocol for the management of patients with the triad, to achieve correction of the obstructed airway , relief of the respiratory distress symptoms, correction of micrognathia and restricted mouth opening . simultaneous distraction and ankylosis release, two stage protocol, where ankylosis was released first and mandibular distraction for advancement was performed in the second stage . Distraction first followed by ankylosis release and simultaneous distractor removal

112. Surgical Management of Temporomandibular Joint Ankylosis Maki et al J Craniofac Surg. 2008 Nov;19(6):1583-8

113. Key points Sufficient exposure Choosing the correct plane of dissection The size and extensions of the bony mass will govern the type of bony resections aggressive resections proper interposition materials strict postoperative physiotherapy

114. Thank you..