TMJ Ankylosis
TMJ Ankylosis
TMJ Ankylosis
JOINT ANKYLOSIS
Contents
Ginglymoarthrodial joint
Articular Surfaces
Mandibular Component
Cranial Component
MANDIBULAR COMPONENT:
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
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%)
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;
• 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;
• 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
Hemarthrosis
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
laryngoscopy
• Periopeartive risk of
desaturation • Fiberoptically assisted nasotracheal
intubation
• Altered upper airway
• Retrograde intubation
intubation
Treatment objectives
• 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
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
Endaural incision
• Short facial skin incision with
extension into the EAM
• Excellent cosmetics
• Limited access
• Poswillo (1974) suggested that the functional matrix theory of Moss forms the basis
• 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.
• 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
Goals
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
bleeding
prosthetic devices
History
• Fossa prostheses
• Condylar prostheses
• Total joint prostheses
Kent- Viket
Synthes
Delrin -Timesh
Christensen I&II
Lorenz
Kent-Vitek prosthesis
condylar prosthesis
• Hemorrhage
• Facial neuropraxia
• Otitis externa & otalgia
• Reankylosis
• Facial scarring
• Auriculotemporal nerve injury- Frey’s syndrome
• Infection
Distraction osteogenesis
soft tissues
• Soft tissues that remain attached to the bone are expanded simultaneously
• Aesthetic correction
• No excision required
• No gap created
• Functional pseudoarthrosis
• The functional pseudoarthrosis relies upon the distance b/w resected bone
tissue is minimal
Extensive ankylosis- resected segment