Tmj & ankylosis ppt

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temporo mandibular joint and ankylosis treatment

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Tmj & ankylosis ppt

  1. 1. Pooja kaloniya 48/2009
  2. 2.  THE TEMPOROMANDIBULAR JOINT IS ALSO KNOWN AS THE CRANIOMANDIBULAR JOINT or BILATERAL DIARTHROIDIAL.  IT IS THE ARTICULATION BETWEEN THE SQUAMOUS PART OF THE TEMPORAL BONE AND THE HEAD OF THE MANDIBULAR CONDYLE.  IT IS ALSO CONSIDERED AS COMPLEX JOINT BECAUSE IT INVOLVES TWO SEPARTE SYNOVIAL JOINT, IN WHICH THERE IS A PRESENCE OF INTRACAPSULAR DISC OR MENISCUS.
  3. 3.  GLENOID FOSSA  ARTICULAR EMINENCE  CONDLYE  SEPARATING DISC  JOINT FIBROUS CAPSULE  EXTRACAPSULAR LIGAMENTS
  4. 4.  COMPRISES OF  Temporomandibular joint  Masticatory and accessory muscles  Occlusion of teeth  The function is governed by sensory and motor branches of the third division of trigeminal nerve.
  5. 5.  MANDIBULAR FOSSA(GLENOID)  IT HAS AN ANTERIOR ARTICULAR AREA BY THE INFERIOR ASPECT OF TEMPORAL SQUAMA.  THE FOSSA IS LINED BY A DENSE AVASCULAR FIBROCARTILAGE.  ARTICULAR EMINENCE  IT SEPARATES THE ARTICULAR SURFACE OF THE FOSSA LATERALLY FROM THE TYMPANIC PLATE.  THE EMINENCE IS COVERED BY DENSE, COMPCT, FIBROUS TISSUE THAT CONSISTS PRIMARILY OF COLLEGEN WITH AFEW FINE ELASTIC FIBERS  TMJ CAPSULE  IT IS A THIN SLEEVE OF FIBROUS TISSUE INVESTING THE JOINT COMPLETY  IT IS A FUNNEL SHAPED CAPSULE,WHICH BLENDS WITH THE PERIOSTEUM OF THE MANDIBULAR NECK AND ENVELOPS THE MENISCUS
  6. 6.  IT REINFORCE THE TMJ CAPSULE  IT EXTENDS DOWNWARD & BACKWARD FROM THE ARTICULAR EMINENCE TO THE EXTERNAL AND POSTERIOR SIDE OF THE CONDYLAR NECK  ITS POSTERIOR FIBER ARE UNITED WITH THE CAPSULAR FIBERS  THIS LIGAMENT IS COMPOSED OF COLLAGENOUS FIBERS THAT HAVE SEPIFIC LENGTH AND POOR ABILITY TO STRETCH, HENCE IT MAINTAINS THE INTEGRITY AND LIMITS THE MOVEMENT OF TMJ  IT MAINLY LIMITS THE ANTERIOR EXCURSION OF THE JAW AS WELLAS PREVENTS POSTERIOR DISLOCATON , ALSO CALLED CHECK LIGAMENT.
  7. 7.  SPHENOMANDIBULAR LIGAMENT  A FLAT BAND ARISING FROM THE APHENOID SPINE AND PETROTYMPANIC FISSURE, RUNS DOWNWARDS AND MEDIAL TO THE TMJ  INTERNAL MAXILLARY ARTERY AND AURICULOTEMPORAL NERVE LIES B/W IT AND MANDIBULAR NECK STYLOMANDIBULAR LIGAMENT IT IS DENCE THICK BAND OF THE DEEP CERVICIVAL FASIA EXTENDING FROM THE STYLOID PROCESS TO THE MANDIBULAR ANGLE.
  8. 8.  THE MENISCUS DIVIDES THE TWO ARTICULAR SPACE INTO TWO COMPARTMENT  LOWER OR INFERIOR COMPARTMENT- condylodiscal complex b/w the condyle and the disc  UPPER OR SUPERIOR COMPARTMENT – b/w disc and the glenoid fossa.  The disc is biconcave in the sagital section.  The superior surface is concavoconvex to match the anatomy of the glenoid fossa.  The inferior surface is concave to fit over condylar head  The disc blends medially and laterally with the capsule, which is attached to the medial and lateral poles of the condyle.  Anteriorly the disc is attached to the articular eminence above & to the articular margin of the condyle below.  Posteriorly disc is attached to the posterior wall of glenoid fossa
  9. 9.  The disc is a meshwork of firmly woven avascular fibrous connective tissue & it is also noninnervated with possible exceptions around its periphery.  These collagen fibers impart flexibility to the disc.  The disc is designed to transmit the forces generated through the condyle to the articular eminence.  It promotes lubrication energy absorption and joint range of motion. It acts as a main shock absorber enabling the articulating bones to move against each other with minimum friction and heat production.  Disc has Avery little potential for repair after inult.
  10. 10.  Lateral aspect is supplied by superfical temporal branch of the external caroid artery.  Rich vascular supply to the deep and posterior aspect of retrodiscal capsular part by deep auricular, posterior auricular & masseteric branches of the internal maxillary artery  Vascular supply to the lateral pterygoid muscle also supplies to the head of the condyle by penetration of numerous nutrient foramina vessels
  11. 11.  THE MANDIBULAR NERVE, THE THIRD DIVISION OF THE FIFTH CRANIAL NERVE INNERVATES THE JAW JOINTS:-  The largest is the auriculotemporal nerve which supplies the posterior, medial and lateral part of the joint  Masseteric nerve  A branch from the posterior deep temporal nerve, supply the anterior parts of the joint
  12. 12.  The movements of tmj are manifold. It is ginglimus diarthroidai type of joint, as it sis capable of rotating around more than one axis and is capable of translatory movement.  MUSCLE FUNCTION- The functions of the muscles of mastication in jaw movement are coordinated and balanced by normal muscle tone.  The muscle of mastication (medial and lateral pterigoid,masseter, buccinator, mylohyoid, temporalis & anterior belly of the digastric) are assisted by the suprahyoid and digastric muscle.
  13. 13.  JAW OPENING It is dominated by daigastric muscle contraction, which depress the body of the mandible. This action is assisted by the suprahyoid, sternohyoid and geniohyoid muscles.  JAW CLOSURE It is accomplished by the simultaneous contraction of the masseter, medial pterigoid muscles.
  14. 14.  PROTRUSIVE MOVEMENT It requires equal simultaneous contracture of lateral and medial pterygoid muscle.  RETRUSION It is brought about by posterior fibers of temporalis muscles, assisted by middle and deep parts of the masseter, digastric and geniohyoid muscles.  LATERAL MOVEMENT These are carried out by unilateral contracture of medial and lateral pterygoid of each side acting alternatively.
  15. 15.  Intra –articular origin or intrinsic disorder  Extra –articular origin or extrinsic disorder
  16. 16.  MASTICATORY MUSCLE DISORDER  Protective muscle splinting  Masticatory muscle inflamation  Masticatory muscle spasm  PROBLEMS DAT RESULT FROM EXTRINSIC TRAUMA  Traumatic arthritis  Fracture  Internal disc derangement  Tendonitis  Contracture of elevator muscle
  17. 17.  TRAUMA  Dislocation, subluxation  Haemarthrosis  Intracapsular fracture, extracapsular fracture  INTERNAL DISC DISPLACEMENT  Anterior disc displacement with reduction  Anterior disc displacement without reduction  ARTHRITIS  Osteoarthritis  Rheumatoid arthritis  Juvenile rheumatoid arthritis  Infectious arthritis
  18. 18.  DEVELOPMENTAL DEFECTS  Condylar agenesis or aplasia- unilateral/bilateral  Bifid condyle  Condylar hypoplasia  Condylar hyperplasia  ANKYLOSIS  NEOPLASM  Benign tumours  Malignant tumours
  19. 19. Surgical access to the tmj is an exacting procedure. Tmj has got close proximity to the main trunk of the facial nerve with its branches in the temporal and facial areas It has also got close proximity to the auriculotemporal nerve and the abundant vascular supply
  20. 20.  ADVANTAGES  Uniform predictability of anatomic exposure & avoidance of a salivary fistula.  Negligible hemorrage  No distortion of anatomic landmarks  DISADVANTAGES  Infection involving the external auditory canal  Paresthesis of the external pinna  Small surgical exposure with poor access and visibility
  21. 21.  ADVANTAGES  Excellent cosmesis  Excellent lateral and posterior exposure with intermediate anterior exposure  DIADVANTAGES  Limited access  Possibility of meatal stenosis
  22. 22.  ADVANTAGES  Excellent cosmesis  Excellent visibility and accessibility  DISADVANTAGES  Close proximity of the posterior facial vein and trunk of the facial nerve  Proximity of the posterior border of the parotid gland  Ideal approach to the condyle neck and ramus
  23. 23.  ADVANTAGES  Inconspicuous location of the incision  Standard approach to the TMJ  DISADVANTAGES  The dissection follows a route through an area which is rice in nerve and vascular supply.  BLAIR AND IVY INCISION  THOMA;S ANGULATED INCISION  AL- KAYAT AND BRAMLEY
  24. 24. Blair’s Inverted Hockey Stick Incision Thoma’s Angulated Incision Dingman’s Incision Popowich & Crane Incision
  25. 25.  ADVANTAGES OF POPWICH’S MODIFICATION  REDUCTION IN INCIDENCE OF FACIAL NERVE PALSY  DECEASED HAEMORRHAGE  IMPROVED VISIBILITY  GOOD COSMETIC RESULTS  REDUCTION IN TOTAL OPERATION TIME  AVOIDANCE OF AURICULOTEMPORAL NERVE ANAESTHESIA  REDUCTION IN POSTOPERATIVE OEDEMA AND DISCOMFORT
  26. 26. MANAGEMENT
  27. 27.  It is a greek terminology meaning “STIFF JOINT”  The jaw function gets affected because of immobility of the joint.  Hypomobility to immobility of the joint can lead to inability to open the mouth from partial to complete.  Onset is usually seen before the age of 10 years.
  28. 28.  FALSE ANKYLOSIS OR TRUE ANKYLOSIS  EXTRA –ARTICULAR OR INTRA –ARTICULAR  FIBROUS OR BONY  UNILATERAL OR BILATERAL  PARTIAL OR COMPLETE
  29. 29. Trauma - At birth (with forceps) - Haemarthrosis - Blow to the chin (causing haemarthrosis) - Condylar fracture - congenital Infections and Inflammatory - Rheumatoid Arthritis - Septic arthritis - Otitis media - Mastoditis - Parotitis - Osteomyelitis - Osteoarthritis - Tonsillitis Systemic disease - Small pox - Ankylosing spondylitis - Syphilis - Typhoid fever - Scarlet fever Others - Malignancies - Post radiology - Post surgery - Prolonged trismus Rare causes - Polyarthritis - measles
  30. 30. TRAUMA Extravasation of blood into the joint space haemarthrosis Calcificatiion and obliteration of the joint space Intra-capsular ankylosis Extra-capsular ankylosis PATHOPHYSIOLOGY
  31. 31.  It depends more upon clinical examination, rather than the diagnostic test.  Restricted or nil oral opening is seen.  Patient will complain of difficulty in mastication.  Protrusive movements are not possible on the involved side.  Partial mobility or complete immobility of the condyle is readily noticed.  Pain is totally absent  In young patient a nature of facial deformity will help to differentiate b/w unilateral and bilateral involvement
  32. 32.  IT VARY ACCORDING TO:  Severity of ankylosis  Time of onset of ankylosis  Duration  EARLY JOINT INVOLVEMENT- less than 15 years: severe facial deformity and loss of function  LATER JOINT INVOLVEMENT- after the age of 15years: facial deformity marginal or nil but functional loss is severe.  Those patient in whom ankylosis develops after full growth completion have no facial deformity.
  33. 33.  Obvious facial asymmetry  Deviation of the mandible and chin on the affected side  The chin is receded with hypoplastic mandible on the affected side  The appearance of the flatness and elongaltion on the unaffected side  The lower border of the mandible onthe affected side hass a concavity that ends in a well- defined antegonial notch  In unilateral ankylosis some amount of oral opening may be possible. Interincial opening will vary depending on whether it is fibrous or bony ankylosis  Cross bite may be seen  Classic angles malocclusion on the affected side plus unilateral posterior cross bite on the ipsilateral side seen  Condylar movements are absent on the affected side
  34. 34.  Inability to open the mouth progresses by gradual decrease in interincisal opening. The mandible is symmetrical but micrognathic.The patient develops typical 'bird face' deformity with receding chin.  The neck chin angle may be reduced or almost completely absent  Antegonial notch is well defined bilaterally  Classii malocclusion can be noticed  Upper incisors are often protrusive with anterior open bite.Maxilla may be narrow  Oral opening will be less than 5mm or many times there is nil oral opening  Multiple carious teeth with bad periodontal health can be seen  Severe malocclusion, crowding can be seen and many impacted teeth may be found on the x-rays.
  35. 35.  History of trauma, infection, etc  Clinical finding  Radiographic finding- are important in arriving at a final daignosis  Orthopantomograph- will show both the joints picture which can be compared in unilateral cases.  Lateral oblique view- will give anteroposterior dimension of the condylar mass. Elongation of coronoid process can be seen.  Cephalometric radiograph- is taken to evaluate the associated skeletal deformities  Posteroanterior radiograph- will reveal the medio lateral extent of the bony mass. It will also highlight the asymmetry in unilateral cases  CT scan- very helpful guide for surgery. Relation to the medial cranial fossa, the anteroposterior width, mediolateral depth can be assessed. Any presence of fractured condylar head on the medial aspect of ramus can be located
  36. 36.  FIBROUS ANKYLOSIS  Reduced JOINT SPACE AND HAZY APPEARANCE CAN BE SEEN.  But, still the normal anatomy of the head and glenoid fossa can be appreciated.  BONY ANKYLOSIS  Complete OBLITERATION OF JOINT SPACE NORMAL TMJ ANATOMY IS DISTORTED.  Deformed condylar head or complete bony consolidation replacing the joint space can be seen.  Elongation of the coronoid process onthe side of hypomobility will be seen.
  37. 37.  Normal facial growth and development affected.  Speech impairment.  Nutritional impairment.  Respiratory distress, especially in bilateral involvement with severe micrognathia.  Malocclusion.  Poor oral hygiene.  Multiple carious and impacted teeth.
  38. 38.  Release of ankylosed mass and creation of a gap to mobilize the joint  Creation of a functional joint  To improve patient's nutrition  To improve patient's oral hygiene  To carry out necessary dental treatment  To reconstruct the joint and restore the vertical height of the ramus.  To prevent recurrence.  To restore normal facial growth pattern.  To improve esthetics and rehabilitate the patient.
  39. 39. Early surgical intervention  Aggressive resection: a gap of atleast 1- 1.5cm should be created. Special attention should be given to fusion on the medial of the ramus.  Ipsilateral coronoidectomy and tempralis myotomy: in most of these cases there is always association of elongated coronoid process. After carrying out gap arthoplasty. The coronoidectomy on the same side should be carried out either separately or in combination with the gap arthroplasy cut from the same etraoral incision.
  40. 40.  Lining of the glenoid fossa region with temporalis fascia  Reconstruction of the ramus with a costochondral graft.  Early mobilization and aggressive physiotherapy for the period of at least six months postoperatively  Regular long-term follow-up  To carry to cosmetic Surgery at the later date when the growth of the patient is completed  Release of the jaw movements is quite dramatic, upon competion of coronoid rather than release it and allow it to be pulled up superior process is removed, there is potential for reankylosis after reattachment.
  41. 41.  Most surgical procedures can be done through a preauricular incision alone.  The popwich's incision is chosen for its obvious advantages  Whenever required additional submandibular incision can be used for fixation of the graft. I : condylectomy II : gap arthroplasty III : interpositional arthroplasty
  42. 42.  It is advocated in cases of fibrous ankylosis, where joint space is obliterted with deposition of fibrous bands , but there is not much deformity of the condylar head.  Radiologically and clinically after surgical exposure one can see the demarcation between the roof of the glenoid fossa and the head of the condyle.  The procedure can be done via preauricular incision  The unilateral condylectomy tends to cause devation of the mandibule towards the operated side on oral opening and if bilateral, anterior open bite will be caused as a result of the loss of the height in the vertical rami.
  43. 43.  Therefore. When the site of the fused joint is mobilized via condylectomy. Then after recontouring by arthroplasty, an alloplastic material can be used to maintain the joint space, satisfactory occlusion and joint movement.
  44. 44.  In the extensive bony ankylosis, a broad,thick area of bone deposition obliterates the entire joint, sigmoid notch and coronoid process  Identification of the previous joint structure is impossible and mobilization at level of joint become difficult  In this operation the level of section is below that previous joint space  The section consist of two horizontal osteotomy cuts and removal of a bony wedge for creation of a gap between the roof of the glenoid fossa and ramus.  Minimum gap of 1cm is recommended to pervent reankylosis
  45. 45.  It involves the creation of gap , but in addition a barrier is inserted between the cut bony surfaces to minimize the risk of recurrence and to maintain the vertical height of the ramus
  46. 46.  Tamporalis fascia along with a varying thickness of temporalis muscle may be harvested as an axial flap based on the middle and deep temporal arteries and veins  The dependable blood supply, the proximity to the tmj and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly, makes this a versitile flap for lining the glenoid fossa.  It is used as an interpositional material after release of ankylosis of tmj.
  47. 47. Basic 3 goals 1. To replicate structurally normal joint anatomy 2. To provide functional articulation 3. To establish an area , where adaptive growth can occurs.
  48. 48.  Costochondral graft is harvested through the infra- mammary incision  Either 5th, 6th, or 7th rib is harvested.  Costochondral junction of rib is chosen along with some amount of length of the rib.  The length of the total graft will depend on the height of ramus to be restored  Minimum of 1.5cm of costochondral junction should be included in the graft  The graft should be fixed on the lateral aspect of the rammus with the screws.  A minimum gap of 0.5 - 1 cm should be kept between the graft and the glenoid fossa side, so that free movement is possible without any friction
  49. 49.  Increased operating time  Additional surgical site  Donor site morbidity  Graft over growth  Possible potential for reankylosis
  50. 50.  DURING ANAESTHESIA  As the patient cannot open the mouth, awake blind intubation has to be done, where patients cooperation is required, which is very difficult to obtain from younger group of patients  Because of small mandible and altered position of the larynx .intubation poses a problem  Aspiration of blood clot tooth or foreign body during extubation as throat cannot be packed prior to surgery  Danger of falling back of tongue and obstructing airway is always there after extubation
  51. 51.  DURING SURGERY  Haemorrage 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 leading entry into middle cranial fossa  Damage to auriculotemporal nerve  Damage to parotid gland  Damage to the teeth during opening of the jaws with jaw stretcher  DURING POSTOPERATIVE FOLLOW-UP  Infection  Open bite  Recurrence of ankylosis
  52. 52.  An inadequate gap created between the fragments  Missing on the medial condylar stump and leaving it behind  Fracture of the costochondral graft  Loosening of the costochondral graft due to inadequate fixation to the ramus  Inadequate coverage of the glenoid fossa surface  Inadequate postoperative physiotherapy  Higher osteogenic potential and periosteal osteogenic power may be responsible for high rate of recurrence in children

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