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TEMPOROMANDIBULAR

JOINT ANKYLOSIS
Contents

• Introduction • Anesthetic considerations


• Terminologies • Management of Ankylosis
• Total joint reconstruction
• Historical perspectives • Autogenous joint reconstruction
• Surgical anatomy of TMJ • Allogenous TMJ reconstruction
• Classifications • Complications
• Etiology of TMJ Ankylosis • References
• Pathogenesis
• Diagnosis
• Clinical features
• Radiographic findings
INTRODUCTION

Bony ankylosis of the mandible is a serious and most disabling


condition. Impairment of speech,difficulty with mastication
,poor oral hygiene, facial asymmetry and mandibular
micrognathia leads to physical and psychologic disability in
affected person.
Definitions

• True ankylosis: It is an intra-capsular condition in which there is fusion of


the bony surfaces of the jaw: the condyle and gleniod fossa.

• Pseudo-ankylosis: It is condition where a mechanical interference causes


joint hypo-mobility and the joint is normal. Conditions like fibrous
ankylosis, coronoid hyperplasia or fusion of coronoid process with the
tuberosity of maxilla or zygoma are examples of psudoankylosis.

• Trismus: It is a condition in which muscle spasm, or contracture (due to


infection or other condition which alter muscle structure) prevents opening
of mouth.
Historical perspectives

• Burton in 1826 described the treatment of ankylosis by the formation of


artificial joints
• Humphry was probably the first surgeon to plan and perform mandibular
condylectomy for ankylosis
• In 1855 Esmarch pointed out a method by establishing pseudoarthrosis
• In 1914 Murphy reported interpositioning a flap of fat and temporal fascia
b/w the 2 cut end of the bones
• In 1942, Pickerill propounded that the ankylosed TMJ should be
reconstructed by means of cartilage graft
Surgical anatomy

Ginglymoarthrodial joint

Articular Surfaces

 Mandibular Component
 Cranial Component

MANDIBULAR COMPONENT:

 Ovoid condylar process


 15 to 20 mm ML and 8 to 10mm AP
 Lateral pole
 Medial pole
 Facing the Posterior slope of the
articular eminence
CRANIAL COMPONENT:

 Inferior aspect of temporal squama anterior to


tympanic plate
 Articular eminence
 Articular tubercle
 Posterior articular ridge and the postglenoid
process
 Lateral border of the mandibular fossa
 Medially the fossa narrows

 Articular disk
Superior joint space
Inferior joint space
TMJ ligaments

3 functional ligaments
• collateral
• capsular
• temporomandibular or lateral

2 accessory ligaments
• sphenomandibular
• stylomandibular
Vascular anatomy
Br of Superficial temporal artery

Br of Transverse facial artery

Posterior deep temporal artery

Posterior tympanic artery

Nerve supply
Facial nerve & TMJ
Etiologic factors- hypomobility

TRISMUS PSEUDOANKYLOSIS
 Odontogenic  Depressed zm arch #
 Infection  Fracture dislocation of condyle
 Trauma  Adhesions of coronoid process
 Tumours  Hypertrophy of coronoid process
 Psychologic  Fibrosis of temporalis muscle
 Pharmacologic
 Myositis ossificans
 Neurologic
 Scar contracture
 Tumour of condyle or coronoid
True ankylosis

 TRAUMA(31—98%)  INFLAMMATION(10%)

 Intracapsular # in child  Rheumatoid arthritis


 Still’s disease
 Medial displaced condylar #
 Ankylosing spondylitis
adults
 Psoriatic arthritis
 Intracapsular fibrosis
 Obstetric trauma  IATROGENIC

 INFECTION(10—30%) Postoperative complication of


 TMJ surgery
 Otitis media  Orthognathic surgery
 Suppurative arthritis
Classifications- Bell’s

 Acute hypomibility
 Mechanical obstruction
 Trauma related

 Chronic hypomobility:
Contracture of elevator muscles
 Myostatic contracture
 Myofibrotic contracture
Capsular fibrosis
Ankylosis
 Fibrous unilateral
 Fibrous bilateral
 Bony unilateral
 Bony bilateral
Classification

KAZANJIAN (1938)
• True ankylosis

• False ankylosis

TOPAZIAN’S
• 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.
Rowe’s classification

• True ankylosis:
 Fibrous
 Fibro-osseous
 Osseous
 Cartilaginous

• Pseudo-ankylosis

• False ankylosis.
Pathologic anatomy
(C. P Sawhney)
• Type I- head flattened/ deformed. Dense
fibrous adhesions all around the joint;

• Type II- head was misshaped/ flattened but


still distinguishable. Bony fusion of the
head of the outer edge either ant/ post.

• Type III- a bony block of bridge across


the ramus of mandible & the zygomatic
arch.The displaced head was atrophic.

• Type IV- bony block was wide & deep


and extended between the ramus and
the upper articular surface, completely
replacing the architecture of the joint.

PRS JANUARY 1986 VOLUME 77, NO. 1


Classification based on CT
(Shashi aggerwal)
• Type I: The condyle can be identified even though flattened,
irregular, partially resorbed. It was usually mesially angulated. The
articular fossa was correspondingly irregular, shallow or deep and
usually sclerosed; the sclerosis extended to adjacent areas of the
temporal bone. There was a mild to moderate amount of bone
formation. This extended from the lateral superior aspect of the
ramus to the squamous temporal bone and / or zygomatic arch,
frequently encroaching on the lateral part of the articular fossa.

• Type II: The joint architecture was completely disrupted with no


recognizable condyle or articular fossa. There was a large mass of
new bone, funnel shaped, extending from the thickened ramus to the
grossly sclerosed and irregular base of the skull.

OOO 1990; 69: 128-32


New Radiographic classification
(Hakim &Metawalli)
• Class I: Includes unilateral and bilateral fibrous ankylosis. The condyle and glenoid
fossa retain their original shape and the maxillary artery is in normal anatomical
relation to the ankylosed mass.

• Class II: There is unilateral or bilateral bony fusion between the condyle and the
temporal bone. The maxillary artery lies in normal anatomical relationship to the
ankylosis mass.

• Class III: The distance between the maxillary artery and the medial pole of the
mandibular condyle is less on the ankylosed than on the normal side or the
maxillary artery runs within the ankylotic bony mass. This is best seen on coronal
CT.

• Class IV: The ankylosed bony mass appeared fused to the base of the skull and
there is extensive bone formation, especially from the medial aspect of the condyle
to the extent that the ankylosed bony mass is in close relationship to the vital
structures at the base of the skull such as the pterygoid plates, the carotids and
jugular foramina and foramen spinosum and no joint anatomy can be defined from
the radiograph This is best visualized on the axial CT.
Dentomaxillofacial Radiology 2002; 31, 19-23
Pathogenesis

Trauma Local infection Systemic infection

Hemarthrosis

Drop in O2 Tension & PH

Promotes Osteosynthesis

Ankylosis
Diagnosis
Diagnosis of the ankylosis is made by history, clinical and radiographic
examination.
Features to be noted as advised by Norman Rowe are

1. History of injury to, or infection of, the jaws.


2. Inability to open mouth or marked limitation.
3. Slight motion of the condyle of the non-involved side.
4. Slight motion from springing of the fibro-osseous tissue on the involved side; in
the bilateral case, movement may be impossible.
5. Asymmetry of the face and areas adjacent to the TMJ.
6. Flattening of face on the unaffected side.
7. Shift of symphysis in unilateral disease towards the involved side.
8. Normal occlusion of the teeth on uninvolved side with crowding and mesial
occlusion in the involved side.
9. Shortness of vertical and horizontal ramus of the mandible on the involved side.
10. Deep antigonial notch on the involved side.
11. Decreased or almost absent joint space or radiograph with a proliferation and
increased density of bone in the joint area.
CLINICAL MANIFESTATIONS
Vary according to
1. Severity of onset
2. Time of onset
3. Duration
Early—12-15 years—severe facial deformity and
loss of function
Late– after 15 yrs.. Facial deformity nil, function loss
UNILATERAL
ANKYLOSIS
• Obvious deformity
• Deviation to affected side
• Chin is receded with hypoplastic mandible on affected side
• Lower border on affected side has concavity(Antigonial notch)
• Cross bite may be seen
• Class II
• Condylar movements absent on affected side
BILATERL ANKYLOSIS
• MIO decreases
• Mandible is micro , symetrical
• Bird face deformity
• Neck chin angle is reduced or absent
• Multiple carious tooth
• Less than 5 mm mouth opening
• Upper incisors often protrusive
• Trismus may also be associated with an open
bite

• Severe oral hygiene maintaince problems


leading to caries & periodontal problems

• Markedly elongated coronoid process


Imaging modalities
Panoramic views
• OPG
• Joint deformity
• Lateral Tomograms • Loss of the joint space
• Abnormal bone formation in and
• PA Mandible around the joint,
• Do not reveal the nature &
• Trans cranial TMJ
extent of the pathology, in
• 3D CT particular the medial & lateral
extension of the ankylosed bony
• MRI mass, & its relation to
surrounding vital structures.
Anesthetic challenges

• Intubation and unco - • Options for securing airway


operativeness
• Nasotracheal intubation via direct

laryngoscopy
• Periopeartive risk of
desaturation • Fiberoptically assisted nasotracheal

intubation
• Altered upper airway
• Retrograde intubation

• CVS and respiratory • Light inhalational anesthesia with


complications speedy release of ankylosis followed by

intubation
Treatment objectives

Restore Restore Allow for Correct Relieve


mouth joint condylar facial airway
opening function growth profile obstruction
Surgical approaches

• PREAURICULAR OBJECTIVES
Maximize exposure
• POSTAURICULAR
Facial nerve
• SUBMANDIBULAR
Major vessels
• POSTRAMAL (HIND’S)
Parotid gland
• CORONAL OR BICORONAL
Maximize use of skin creases
• ENDAURAL
Preauricular incision
• Most basic and standard
approach

• Standard- Dingman
Modifications- preauricular

Thoma in Al-Kayat &


Blair and Ivy in 1958- Bramley in Popowich and
1936- inverted angulated 1979- modified Crane in 1982-
hockey stick vertical preauricular question mark
incision approach
Popowich incision

Reduction in incidence of facial nerve palsy


Provision of donor site for temporalis fascia
Decreased hemorrhage
Improved visibility and easier identification of fascial planes
Reduction of postop edema and discomfort
Potential complications of muscle herniation & fibrosis avoided
Good cosmetic results
Avoidance of auriculotemporal nerve anesthesia/ paresthesia
Reduction in total operating time
Postauricular approach
• Normal scar formation
• Healthy ear apparatus & absence of aural sepsis
• Normal width of EAC
• Absence of inflammation/ infection of the joint structures
• General health of the pt

Advantages
• Excellent exposure of the entire joint
• Ability to camouflage the scar in patients – keloids.

Disadvantage
• Auricular stenosis
Submandibular approach
• Atleast 2cm below mandible
• In cases where access through preauricular
approach alone may be unsatisafactory

Postramal incision
• Incision runs parallel and
posterior to the ascending ramus
at a distance of 2cm

• Parotidomassetric fascia is
separated

• Ascending ramus is approached


posteriorly
Coronal approach
• Versatile approach to the upper &
middle regions of the facial
skeleton
• Minimum complications
• Scar hidden within the hairline

Endaural incision
• Short facial skin incision with
extension into the EAM

• Excellent cosmetics

• Limited access

• Possibility of meatal stenosis


Rhytidectomy approach
Treatment options

• Condylectomy- procedures involving section through the


fused mass at the level of the original joint space to relieve
ankylosis

• Gap arthroplasty- generally used to describe those operations


in which the level of section is below that of the previous joint
space and in which no substance is interposed b/w the cut
bony surfaces . The width of bone removed is considered
to be crucial- minimum of 1cm

• Interpositional arthroplasty- involves the creation of the gap in


addition a barrier is inserted between the cut bony surfaces to
minimize the risk of recurrence & to maintain the vertical
height of the ramus
OOO VOLUME 55, NUMBER 6 JUNE 1983
Ankylosis

Class I Class II Class III Class IV

Remove bony bridge


Meniscus intact Meniscus lost (usually
extracapsular),
Functinal
components of joint
Horizontal cuts to
Interpositional intact
Gap remove a chunk of
arthroplasty material like ankylosed mass
with 3 – 5 temporalis
mm gap fascia or silatic
etc can be used
Surgery in childhood

• Interceptive surgery- recent concept

• Poswillo (1974) suggested that the functional matrix theory of Moss forms the basis

• Early reconstruction with CCG- adaptive remodeling

• Rowe (1982)- restoration of mobility of the mandible should be undertaken ASAP

• Higher recurrence rate, unpredictable bone growth, difficulties with compliance,


concerns for perioperative iatrogenic disturbance to growth

• To avoid secondary deformities

• Growth centers such as CCG is necessary; mandibular growth increased after


release of ankylosis

• Condylectomy or osteoarthrectomy with CCG


Adult ankylosis

• Gap arthroplasty, coronoidectomy

• To extirpate an unusually large mass- area of pathology could be bypassed

• Risdon’s incision- surgeon creates a gap through from the sigmoid notch to
the posterior border of the ramus

• Two parallel cuts are made to effect the ostectomy with the bone removed-
false, functional joint created.

• Acceptable hinge opening – lateral excursions are limited.

• Interpositional and total joint replacement


Modified Kaban’s Protocol
Gap arthroplasty

• Surgial exposure using preauricular incision

• Exposure of ankylosed joint

• Liberal resection of the ankylotic joint and coronoid process

• Burring of the glenoid fossa

• Creating at least 15mm b/w the roof of the fossa & the

mandible
Surgical technique
Gap arthroplasty

Advantages Disadvantages
• Simplicity • Pseudo-articulation
• Short operating time • Short ramus height
• Failure to remove all bony
disease
• Development of open bite
{bilat cases}
• Suboptimal range of motion
• Recurrent ankylosis (60%)
Interpositional arthroplasty
• Since 1893, the advocated treatment –
autogenous tissue

• Many authors agree that recurrence of


ankylosis is less likely

• Topazian- comparison study- 53% incidence


of recurrence

• In past, fascia lata, adipose tissue, muscle


full thickness skin & cartilage

• Alloplastic- silicone rubber

• Sound technique in adults in whom the size


of the mandible & the jaw relationship are
acceptable
OOO VOLUME 55, NUMBER 6 JUNE 1983
Interpositional materials
Autogenous Heterogenous Alloplastic
Costochondral Chromatized submucosa of Metallic-
pig bladder tantalum foil/ plate
Metatarsal Lyophilized bovine 316L stainless steel
cartilage
Sternoclavicular Titanium
Auricular cartilage Gold
Temporal fascia Nonmetallic
Fascia lata Silastic
Dermis Teflon
Acrylic
Nylon
Proplast
Ceramic implants
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
Autogenous TMJ replacement

• 1909 – Bardenheur - replaced condyle - 4th metatarsal


• 1920 - Gillies used costochondral graft

Donor site alternatives


• Ramus condylar unit • Glenoid fossa lining

• Costochondral graft • Dermis graft

• Metatarsal head graft • Auricular cartilage graft

• Sternoclavicular joint graft • Temporalis myofascial flap

• Calvarial bone graft


RCU reconstruction- Rib
Purpose of using costochondral grafts for reconstruction of TMJ ankylosis is twofold:

1) To ensure a wide gap arthroplasty for release of the ankylosis,

2) To restore the joint’s form and function.

ADVANTAGES
• Biologic acceptability and remodeling by oppositional growth, especially in
children

DISADVANTAGES
• Increased operating time
• Additional surgical site

COMPLICATIONS
Donor site morbidity
• Pneumothorax & pleuritic pain
• Potential overgrowth of the graft
• Suboptimal postoperative range of motion
Glenoid fossa reconstruction

• Glenoid fossa and zygomatic construction through - coronal


incision
• Zygomatic arch- full thickness calvarial bone
• Cortical graft of autogenous rib, ileum or calvaria is anchored
medial to the constructed zygoma to create a concave surface-
condyle
• The constructed GF is lined with a suitable joint such as dermis,
cartilage/ temporalis fascia
Postoperative care

• Monitoring of the airway and watchfulness of

bleeding

• Antibiotics- I/O approach + bone grafts/

prosthetic devices

• Physical therapy- postop phase of ankylosis

Should be instituted ASAP ?

• Ice packs followed by hot packs

• Finger exercises- first days after surgery

• Large bundles of tongue depressors- wedge


Alloplastic joint replacements

History

• 1840– John Murray treated ankylosis - wood block


• 1890– Gluck - ivory prosthesis
• 1933 – Risdon – gold foil
• 1947 – Goodsell - titanium foil
• Total joint - Kent-Vitek prosthesis
• Christensen – 1964 - lined glenoid fossa —vitallium
• Chase – 1995 - chromium cobalt head
Indications Relative Contraindications

• Ankylosed, degenerated or resorbed • Insufficient patient age


joints with severe anatomic
• Lack of understanding of the
discrepancies
patient
• Failed autogenous bone grafts
• Destruction of autogenous bone due
• Uncontrolled systemic disease
to preexisting foreign body reaction. • Allergic to materials used in
• Recurrent ankylosis. devices
• Severe polyarticular inflammatory • Active infection at
joint disease of TMJs
implantation site
Advantages Disadvantages

• Physical therapy begin immediately • Cost of prosthesis


• No need for second donor site
• Material wear and failure
• Reduced surgical time
• Long term stability
• Mimic normal anatomic contours,
better adapted to bony surfaces. • Inability to follow patients growth
• Stable occlusion; decreased
• Potential for severe giant cell
hospital stay
• Opportunity to manipulate reactions

prosthesis design to discourage


heterotrophic bone formation
Alloplastic condylar prostheses

• Fossa prostheses
• Condylar prostheses
• Total joint prostheses

 Kent- Viket
 Synthes
 Delrin -Timesh
 Christensen I&II
 Lorenz
Kent-Vitek prosthesis

• VK-1 consisted of a bilaminate


fossa with a polyaramid fabric-
reinforced ultra-high MW,
polyethylene articular surface.

• Inner layer- proplast- HP

• Condylar prosthesis- Cr- Co with


layer of proplast

• VH-2 ultra HMWPE


Christensen’s prosthesis
• Most commonly used

• Original cast Co- Cr was available in


20 different sizes

• Highly polished articulating surface


of the fossa was designed to articulate
directly with a directly with a natural
condyle

• Majority of pts had an increase in


their functional abilities and decrease
in pain
Total TMJ reconstruction
• In a comparative study of the Christensen prosthesis &
the CAD/ CAM generated custom- made prosthesis: the
custom made prosthesis had a statistically significant
improvement
• Subjective analysis- safe and effective long term
management modality in the pt population surveyed

• When condyle is rendered nonfunctional


• Bony/ fibrous ankylosis
• Severe degenerative , rheumatoid
• Congenital absence of condyle
• Malocclusion with facial deformity
Technique
• Proper surgical access for placement of both a fossa and a

condylar prosthesis

• Combination of an endaural incision- modified rhytidectomy

incision & posterior mandibular incision

• Great care is taken not to incise the perichondrium on the tragal

cartilage during the initial incision

• Dissect along the tragal cartilage to the root of zygoma and

establish a single plane of dissection


Complications

• Hemorrhage
• Facial neuropraxia
• Otitis externa & otalgia
• Reankylosis
• Facial scarring
• Auriculotemporal nerve injury- Frey’s syndrome
• Infection
Distraction osteogenesis

• Simultaneous correction of defects- difficult

• Gradual distraction is a simple and effective procedure for increasing the

soft tissues

• Soft tissues that remain attached to the bone are expanded simultaneously

• The elongation of muscles, ligaments, vessels- radical procedures

• Corrects secondary facial deformity

• Aesthetic correction

JOMS 58: 1415-1418; 2000


Cranio-mandibular ankylosis
• Although the bony mass ankylosis- not a
neoplastic process

• No excision required

• Management of ankylosis is convert into


subcondylar fracture

• The 2 margins of the osteotomy cut are


distracted to create a space- no bone
removed

• Thickness of block- 6-8mm; temporalis


muscle- medial surface of ramus
• The ankylotic mass is not resected

• No gap created

• Functional pseudoarthrosis

• The functional pseudoarthrosis relies upon the distance b/w resected bone

surfaces & interpositional material

PHILOSOPHY: pseudoarthrosis is encouraged to form the normal bone- scar

tissue is minimal
Extensive ankylosis- resected segment

• In extensive ankylosis in adults


new method for reconstruction
was considered
• Autogenous graft consisting of
excised ankylotic mass
• 20x25mm contoured and used to
maintain vertical height
• Consists of dense bone and
smooth cortical surface

JOMS 1997; 26: 405- 407


References

• A TEXTBOOK & COLOUR ATLAS OF TMJ DISEASES, DISORDER, SURGERY


- J. E. DeBURGH NORMAN
• MAXILLOFACIAL TRAUMA – ROBERT H. MATHOG
• SURGERY OF THE TMJ – DAVID ALEXANDER KEITH
• TEMPOROMANDIBUALR DISORDERS CLASSIFICATION, DIAGNOSIS,
MANAGEMENT - WELDEN E. BELL
• ORAL AND MAXILOFACIAL INFECTIONS – TOPAZIAN
• TEXT BOOK OF ORAL MEDICINE – BURKETT.
• TEMPOROMANDIBULAR DISORDERS – KAPLAN
• MANAGEMENT OF TMJ DISORDERS AND OCLUSION – JEFFREY OKESON
• MAXILLOFACIAL SURGERY – PETER WARDBOOTH
• Leonard B Kaban, David H Perrott, Keith Fisher JOMS; 48; 1990: 1145-51

• New Perspectives In The Management Of Cranio-Mandibular Ankylosis. P


C Salins, IJOMS, 2000; 29; 337-40

• Bone Ankylosis of the TMJ. A CT study Sashi Aggarwal, Sima

• Mukhopadhyaya, Manorama berry, OOO; 1990; 69: 128-32

• Imaging of TMJ; A New Radiographic Classification. IE El-Hakim,S A


Metwalli Dentomaxillofacial Radiology 2002; 31; 19-23.

• JOMS 65:2466-2469, 2007