Management of Temporomandibular Joint Ankylosis

MANAGEMENT OF
TEMPOROMANDIBULAR JOINT
ANKYLOSIS
INTRODUCTION
Ankylosis --- Ankylos (Greace) --- joint stiffness
Temporomandibular joint (TMJ)
Affect function, esthetic & psychological problem
Treatment : conservative & surgical
Evaluation of the diagnostic records

DEFINITION
TMJ Ankylosis
Restricted movement of the mandible

may be due to intra capsular & extra
capsular
Ankylosis (Greek) = ankylos  stiff joint
 “ fusion of bones surrounding joint “
 “calcium deposit around ligament”
Peterson  Ankylosis : fusion of the

condyle, disk, and fossa complex, as
a result of the formation of fibrous
tissue, bone or a combination of the
two
Temporomandibular Joint (TMJ)
 Composed of
 Condyle
 Mandibular fossa
 Articular capsule
 Synovial tissue
 Articular disc
 Ligaments
5
ETIOLOGY OF TMJ ANKYLOSIS
TRAUMA INFECTION NEOPLASMA

-Birth trauma -Primary -Benign
-Haemarthosis & infection -Malignant
contusio of articularis -Secondary
disc infection
-Vulnus combustio
-Fracture of arcus
zygomaticus &
proc.coronoideus
Etiology and Pathogenesis
 Basic : hemarthrosis  fibroosseous
Trauma
Infection
Past TMJ surgery
Orthognatic surgery
Trauma  ankylosis :
 Age
 Severity of trauma
 Fracture location
 Immobilization duration
 Articular disc
CLASSIFICATION OF ANKYLOSIS
Classification of ankylosis (Turker, 2003)
1.EXTRACAPSULAR ANKYLOSIS
2.INTRACAPSULAR ANKYLOSIS
1.Fibrous ankylosis
2.Bony ankylosis
Classification
Intra articular
Location
Extra articular
Type of tissue Bony

involved Fibrous
Mixed
Extent of fusion Complete (True ankylosis)

Incomplete (pseudoankylosis)
True ankylosis
Stage I : bony ankylosis limited to

condyloideus processus
Stage II : bony ankylosis extended to

sigmoid notch
Stage III : bony ankylosis extended to

coronoideus processus
FALSE ANKYLOSIS (PSEUDOANKYLOSIS)
Extra articulare
miogenic, neurogenic,
Trismus
atau psikogenic
prolong mandible
Atrofi / muscle fibrosis
disfunction
Myositis ossificans masseter
clostridium tetani , muscle

Extra articulare Tetanus
spasm, lock jaw
neuro cases , epilepsy,

Neurogenic closure
brain tumor
Trismus histerical rare psycogenic disorder
Mechanical blocking
Chief complaint : unable to open the
mouth
Mastication difficulty
Bad OH
Multiple caries
opening mouth
Ankylosis in growth periode
Extra oral
Deviation of chin and mandible to affected
side
 Unilateral vertical deficiency in affected side
Retrognathi mandible with short ramus and
small body
Maxilla retrusion
Microgenia
Convex face profile
Short hyoid –mental distance with
suprahyoid muscle spasm
No cervico-mental angle
Bird face deformity
Ante-gonial notch protruding
Intra Oral
 Maxilla and mandible midline deviation

to affected side
 Commonly class II malocclusion
 Posterior crosssbite
 Deviation to affected side while opening
the mouth
 Trismus
 In bilateral ankylosis, trismus often
followed by open bite
 Very bad OH, caries, and periodontal
involvement
 Coronoideus processus elongation
 3.Other features
 Obstructive sleep disorder –
oropharynk airway narrowing in sefalo-
caudal, sefalo-caudal, transverse, and
anteroposterior
Radiograph
Fibrous ankylosis
Bony Ankylosis
EVALUATION & DIAGNOSIS
Careful evaluation of the diagnostic records

ideal treatment plan
successful of treatment
1.Anamnesis
2. Clinical examination
3.Radiographic examination
Anamnesis : 1. Etiology
2. Duration
3. Age
Clinical examination :
1. Extra oral examination
2. Intra oral examination
Radiographic
Diagnostic ideal treatment plan

Extra oral examination :

-Palpation in pre auricular – no mobility
-Scar examination --- mandible, posterior of the
ear
-Angular notch
UNILATERAL ANKYLOSIS
-Facial profile --- deviation of the mandible ---
growth age
-Flat of the face --- contra lateral site --- in
activity of the masticatory muscle
EXTRA ORAL EXAMINATION
A B C
Fig 2 : A. Unilateral fibrous ankylosis (Van Der Wal, 1982)
B. Unilateral fibrous ankylosis (lateral)
C.Effort of the mandible movement
Intra oral examination :
-Restricted of the mandible movement 

partial or total
-Oral hygiene 
-Mal position & mal occlusion
-Deviation of midline central incisive

INTRA ORAL EXAMINATION
A B
Fig 4 :Intra oral examination (Van Der Wal, 1982)

A. Sagital line B. Malposition teeth
Radiographic examination :
1. Orthopantomogram radiographic
2. TMJ radiographic
3. Schedle lateral
4. Lateral oblique of the mandible
5. Submentovertex
6. CT Scan
7. MRI
TREATMENT
to improve joint mobility back to normal
Conservative Surgery
1. Exercise 1. Condillectomy
2. Corticosteroid 2. Gap Arthoplasty
injection 3. Interposition
3. Arthroscopy arthroplasty
4. Ostectomy
Treatment of post surgery --- physiotherapy

CRITERIA OF SUCCESSSFUL OUTCOME
a symptomatic
Movement of the mandible --- maximal
no complication
no reankylosis
no disturbance of growth
Restoration Oral Hygiene
ANKYLOSIS THERAPY
Conventional  physical exercise, emergency case, fibrous ankylosis
Arthrocentesis
 Intra articular injection
Surgery
Aim : optimalisation mouth opening, joint
function, condyloideus growth and face profile
Arthroscopy
Gap arthroplasty
Interposition
Post operative care
 Mobilizationstarting at day 3-6 continu
to 3-6 months
 IMF3 weeks reach good occlusion
 Physiotherapy prevent re-ankylosis
 Posible complication: pain, re-
ankylosis,maloclusion, esthetic
disturbance
CONCLUSION
-Ankylosis --- joint stiffness --- ankylosis of TMJ

--- Affect function, esthetic & psychological
problem
-Evaluation of the diagnostic records --- ideal

treatment plan --- clinical examination &
radiographic
-Treatment : to improve joint mobility back to

normal (conservative & surgical).
Thank You

Management of Temporomandibular Joint Ankylosis

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MANAGEMENT OF

Ankylosis --- Ankylos (Greace) --- joint stiffness

Temporomandibular joint (TMJ)

Affect function, esthetic & psychological problem

Treatment : conservative & surgical

Evaluation of the diagnostic records

Restricted movement of the mandible

Peterson  Ankylosis : fusion of the

TRAUMA INFECTION NEOPLASMA

Classification of ankylosis (Turker, 2003)

Type of tissue Bony

Extent of fusion Complete (True ankylosis)

Stage I : bony ankylosis limited to

Stage II : bony ankylosis extended to

Stage III : bony ankylosis extended to

Myositis ossificans masseter

clostridium tetani , muscle

neuro cases , epilepsy,

Trismus histerical rare psycogenic disorder

 Maxilla and mandible midline deviation

Careful evaluation of the diagnostic records

Diagnostic ideal treatment plan

Extra oral examination :

Intra oral examination :

-Restricted of the mandible movement 

-Mal position & mal occlusion

-Deviation of midline central incisive

Fig 4 :Intra oral examination (Van Der Wal, 1982)

to improve joint mobility back to normal

Treatment of post surgery --- physiotherapy

-Ankylosis --- joint stiffness --- ankylosis of TMJ

-Evaluation of the diagnostic records --- ideal

-Treatment : to improve joint mobility back to

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