TMJ Ankylosis
TMJ Ankylosis
TMJ Ankylosis
➢Trauma
Particularly intracapsular and subcondylar fractures
➢Infection
Local (ear, odontogenic, skin)
Systemic (osteomyelitis from long bones)
➢Systemic illness
Ankylosing spondylitis
Juvenile rheumatoid arthritis
Psoriasis
➢Radiotherapy
Parotid, bone and soft tissue tumours
➢Previous surgery to joint
PATHOPHYSIOLOGY
TRAUMA
Haemarthrosis
Activate osteoblasts
Bone formation
1. Bilateral or unilateral,
2. Fibrous or bony,
4. Complete or partial,
5. True or false.
KAZANJIAN (1938)
INTRA-CAPSULAR ANKYLOSIS EXTRA-CAPSULAR ANKYLOSIS
➢Time of onset
➢Severity
➢Duration
➢Unilateral or bilateral
CLINICAL CONSEQUENCE
FUNCTION AND ➢Restriction of mandibular motion
ESTHETICS ➢Deviation of the mandible to
ankylosed side on opening
➢Impaired Speech
FUSION OF MANDIBULAR
CONDYLE TO BASE OF ➢Mandibular deficiency, bird fascies
SKULL “vogelgesicht”Facial asymmetry
➢Varying degree of malocclusion,
caries tooth, poor oral hygiene,
halitosis
PSYCHOLOGICAL STRESS
➢Hypertrophic suprahyoid
musculature
➢Compromised Airway
ANTEGONIAL NOTCHING IN ANKYLOSIS
➢Class I : Ankylotic bone tissue limited to the condylar process and articular fossa.
➢Class II : The bone extends out of the fossa involving the medial aspect of the skull base
up to the carotid- jugular vessel.
➢Class III : Extension and penetration into the middle cranial fossa.
➢Class IV : Combination of class II and III.
SASHI AGGARWAL, MANORAMA BERRY ET AL 1990
(B ASED ON CT FINDINGS) 3 -0 . 1990 :69
➢Type I : Medially angulated condyle with deformed articular fossa and a mild to moderate amount
of new bone formation. Condyle can be identified – The articular fossa has corresponding
irregular, shallow or deep and usually sclerosed, the sclerosis extending to the adjacent areas of the
temporal bone.
(Aetiology specific – trauma associated)
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 relation to the ankylosed mass.
Class III: the distance between the maxillary artery and the medial pole of the mandibular condyle is less on the ankylosed
than in the normal side or the maxillary artery runs within the ankylotic bony mass. This is best seen on coronal CT.
Class IV: the ankylosed 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 carotid and jugular foramina and foramen spinosum and no joint
anatomy can be defined from the radiograph. This is best visualized on axial CT.
HE ET AL CLASSIFICATION
J ORAL MAXILLOFAC SURG 69:1600-1607,
2011 A2
➢A1: Fibrous ankylosis without a bony component,
➢To improve joint movement and function, which requires meticulous and radical
removal of the ankylosed bone or creation of pseudo joint.
Salins in 2000 gave a new perspective in the management of the ankylosis by performing
an osteotomy inferior to the ankylotic mass (subankylotic approach) and
producing a pseudoarthrosis.
The author advocates use of temporalis muscle flap and interpostional substance of 7
to 8 mm thick to prevent reankylosis.
Salins (2000) concept
This technique differ from conventional technique in the following aspect :
➢The ankylotic mass is not resected / manipulated.
➢Bone is not removed to create a gap as in the case of gap arthroplasty.
➢A functional pseudoarthrosis is created between normal bone surfaces.
➢The use of distraction osteogenesis (DO) has been described for reconstruction of the
excised segment.
➢In this instance the condylar segment is excised as normal but a cortical osteotomy is
performed.
➢A mini distractor is placed and active distraction commences after a two to four day latency
phase. Distraction proceeds at rate of 1 mm per day until the neo condyle makes contact
with the skull base.
➢The advantages of this technique include the lack of donor site morbidity as well as the
potential to begin rehabilitation of the joint immediately following surgery.
➢The disadvantages of DO include the risk of infection as well as failure of distraction.
Additionally, the proximal ‘condyle’ lacks a growth centre conferring a risk of developing
mandibular asymmetry and malocclusion.
SURGICAL PROCEDURES
➢Condylectomy
➢Gap arthroplasty
Postauricular
Coronal, Hemicoronal
Retromandibular
Submandibular
Rhytidectomy
INCISIONS
Risdon’s Blair’s
Submandibular Inverted Dingman’s Thoma’s Popowich & Crane
Hockey Preauricular Angulated
Alkayat and
Aleaxander and James Hind’s Postramal Lamport’s Bramley
Post auricular Endaural
ANCILLARY BUT CONTROVERSIAL
➢These exercises should be performed frequently (four to five times per day) for
several minutes at a time.
Med Hypotheses. 2012 May;78(5):682-6. doi: 10.1016/j.mehy.2012.02.010. Epub 2012 Mar 9. PMID: 22406097.
MANAGEMENT OF
TRIAD
PATIENTS
MODIFIED KABAN PROTOCOL
TREATMENT OF TEMPOROMANDIBULAR
JOINT ANKYLOSIS WITH TOTAL JOINT
RECONSTRUCTION
ORAL MAXILLOFACIAL SURG CLIN N AM 27 (2015) 27 –35
Mean follow-up 50.4 months. Reza Movahed, DMD, Louis G. Mercuri, DDS, MS
Results
52% reduction in pain, and
improvement in jaw
function (76%), diet (72%), and
maximum incisal
opening (MIO) (140%) from
11.75 mm to
32.9 mm, whereas 17 of 20
patients (85%) re-
ported improvement
in quality-of-life scores
Mercuri and colleagues evaluated 20 patients
with 33 reankylosed TMJs managed with patient- Wolford and Karras published the first study evaluating fat
fitted TMJ TJR devices and placement of periartic- grafts placed around TMJ total joint prostheses.
ular autogenous abdominal fat grafts.
REFERENCES
➢ Textbook of Association of Oral and Maxillofacial Surgeons of India , Chapter 65 ; Sonal Anchila p 1401-35
➢ Andrade NN, Nerurkar SA, Mathai P, Aggarwal N. Modified Cut for Gap Arthroplasty in Temporomandibular
Joint Ankylosis. Ann Maxillofac Surg. 2019 Jul-Dec;9(2):400-402. doi: 10.4103/ams.ams_269_18. PMID:
31909023; PMCID: PMC6933955.
➢ Kaban LB, Bouchard C, Troulis M. A protocol for management of temporomandibular joint ankylosis in children.
J Oral Maxillofac Surg 2009; 67(9): 1966–78.
➢ Kundra P,Vasudevan A, Ravishankar M.Video assisted fiberoptic intubation for temporomandibular ankylosis.
Pediatric Anaesthesia 2006;16: 458–61.
➢ Dean A, Alamillos F. Mandibular distraction in temporomandibular joint ankylosis. Plast Reconstr Surg 1999;
104: 2021.
➢ R. Gunaseelan: Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using
resected segment as autograft. A new technique. Int. J. Oral Maxillofac. Surg. 1997; 26: 405-407.
REFERENCE