3. INTRODUCTION
The TMJ is one of the most complex joints in the body being
responsible for the various movements of the jaws, any pain or
restriction of function can cause immense distress to the patient
7. CLASSIFICATIONS
Topazian classification (1966)
Type I : Fibrous adhesion in / around front restricted condyle
Type II : Bony bridge between condyle & glenoid fossa
Type III : Condylar neck is ankylosed to fossa completely
8. Rowe’s (according to the tissue involved )
Fibroosseous ankylosis
Osseous ankylosis
Cartilagenous ankylosis
Osteo cartilagenous ankylosis
9. Sawhneys classification (1986)
Type I : presence of fibro-adhesions at the condyle
Type II : bone fusion with condyle remodelling and an intact
medial pole
Type III : ankylotic mass, mandibular ramus union with the
zygomatic arch and medial pole intact
Type IV : complete ankylotic mass, total union of the
mandibular ramus with the zygomatic arch
10. TYPE OF ANKYLOSIS
TRUE
FIBROUS Fibrous callus replacing normal joint
• Osseous/ fibrocartilagenous mass
replacing joint
• Disc often replaced by bone/fibrous
tissue
• Immobile joint
11. ETIOLOGY
Trauma
At birth (with forceps)
Blow to the chin (causing haemarthrosis )
Condylar fracture
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
12. PATHOPHYSIOLOGY
TRAUMA
Extravasation of blood into the joint space
Haemarthrosis
Calcification and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
13. Intra-capsular ankylosis
destruction of the meniscus
flattening of the temporal fossa
thickening and flattening of the condylar head
narrowing of the joint space
Opposing surfaces then develop fibrous
adhesions that inhibit normal movements and
finally, may become ossified.
Extra-capsular ankylosis
There’s an external fibrous
encapsulation with minimal destruction
of the joint itself.
14. PATHOPHYSIOLOGY
In ADULT (Less common)
Thin neck common site of fracture.
Dense condylar head with thick cortex.
Sub articular plexus absent.
PATHOPHYSIOLOGY
Blow to chin
sub condylar fracture
extracapsular haematoma
telescoping of the fracture
distal mandibular fragment goes up & may contact zygomatic arch or base of skull
if displace medially—> post trauma exercise delayed —>organization of extracapsular—
>haematoma —>reunion of distal mandibular stump with bony structure above
ANKYLOSIS.
If condyle displace laterally,
external fibrous encapsulation with minimal destruction of the joint itself
—>Extra-capsular ankylosis
15. Extra articular ankylosis :
Jacob’s disease – osteochondroma of the coronoid process causing
symptomatic enlargement with subsequent fusion to the base of the zygoma
SHABTAE & SCHWATRZ – also reported fusion of ramus and zygoma by
mandibular osteotomy
KARRAS – reported ostechondroma of the mandibular condyle and ispilateral
cranial base
17. CHILD (ROWE’S THEORY )
Thin Cortical Bone
Subarticular Interconnection Plexus Of Blood Vessels
With Flow Of Blood Vessels Extending Towards The
Articulating Surface After Penetration Of Bone
Neck Is Thick
18. TRAUMA TO CHIN
INTRACAPSULAR FRACTURE
HAEMARTHROSIS + HIGHLY OSTEOGENIC
POTENTIAL FRAGMENTS OF CORTICAL
LAYER OF CONDYLE.
NO AGGRESSIVE PHYSIOTHERAPY AFTER
TRAUMA
ORGANIZATION OF HAEMATOMA
FORMATION OF BONE ANKYLOSIS
19. Infection & inflammation
Infection – inflammation – leukocytic activity increases -
lysozymal enzymes released – tissue distraction , damage to
synovial membrane – necrosed tissue replacement – granulation
tissue filled the joint space - fibrosis occurs with time –
ossification or calcification of the fibrotic mass
20. TYPES OF ANKYLOSIS
TRUE ANKYLOSIS
U/L
Secondary to trauma
Intra- articular
Usually fibrous but may ossify
FALSE ANKYLOSIS
Affecting muscles,
VII N,
coronoid process
Extra- articular
26. OBJECTIVES OF THE TREATMENT
✦ Creat a gap to mobilize the 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 improve esthetics and rehablitate the patient
27. KABAN’S PROTOCOL ( 1990 )
• Early surgical intervention.
• Aggressive resection of the ankylotic segment .
• Ipsilateral coronoidectomy .
• Contralateral coronoidectomy & temporalis myotomy necessary if max.incisal opening < 35mm .
• Lining the joint with temporalis fascia and cartilage.
• Recontruction of the ramus with costochondral graft.
• Rigid fixation of the graft.
• Early mobilization and aggressive physiotherapy.
28. KABAN’S PROTOCOL (2009)
• Early surgical intervention.
• Aggressive resection of the ankylotic segment.
• Ipsilateral coronoidectomy .
• Contralateral coronoidectomy & temporalis myotomy necessary if max.incisal opening
< 35mm .
• Lining the joint with temporalis fascia and or the native disc if it can salvaged
• Reconstruction of ramus condyle unit either by distraction osteogenis or a costocondral
graft and rigid fixation
• Early mobilization of the jaw if DO after 1 st post operative day if CCG after 10 days of
MMF postoperatively
29. By Sahwney acc. to the type of ankylosis;
Type I & II – a discrete section of condyle is excised with a reciprocating saw a gap of 3 – 5 mm is made, fibrous
adhesion is removed if meniscus is intact no interpositional material is required if meniscus is damaged / absent
interpositional material is inserted
Type III -- extra-articular bony bridge extending from zygomatic arch to the ramus is removed
Type IV – new joint is fashioned to restore function in children(12-13) IMF for 10 – 14 days followed by early
mobilization and physiotherapy
Acc. To Ware & Munroe et al. costochondral graft should be used
30. Anaesthetic challenges
For child
Difficult intubation
Nutrionally challenged—so trachea smaller than others
Post extubation —desaturation obstructive sleep apnea
For adults
Associated ankylosis spondylitis
Nasotracheal intubation
Awake tracheostomy
Blind nasal intubation
Retrograde intubation
Fiberoptic nasotracheal intubation
Ventilatory bronchoscope
31.
32. Surgical anatomy
Outer aspect of zygomatic arch to MMA=31mm
MMA to glenoid fossa (AP distance)= 2.4mm
Zygomatic arch to carotid artery= 37.5mm
Zygomatic arch to IJV= 38.3mm
Zygomatic arch to mandibular N = 35mm
Gleniod fossa to mandibular N = 9.2mm
33. Areas of concern
Proximity of medial aspect to structures of infra temporal fossa
Excessive bleeding- Internal max. Artery
Presence of retrodiscal venous plexus
34. Surgery outline
Temporalis fascia flap Under GA, increase in gap arthroplasty of 1.5-2cm
Costochondral graft placed stabilized wit plate & screw
Ipsilateral / contralateral coronoidectomy
Genioplasty
42. Aggressive excision of fibrous/bony mass
Coronoidectomy on affected side
Coronoidectomy on opposite side if MIO>35mm or to point of dislocation of opposite side
Lining of the joint with temporalis fascia or the native disc if salvaged
Reconstruction of RCU with DO or CCG and rigid fixation
Early mobilisation - if DU used to reconstruct RCU, mobilise on day of surgery; if CCG used,
early mobilisation with minimal IMF ( not > 10 days)
Aggressive physiotherapy
43. Gap arthroplasty ABBE (1880)
- Gleno mandibular dysjunction
-1cm bone removal minimum
SALINS - Ankylosis subcondylar #
- Pseudoarthrosis with post op
physiotherapy
44. Interpositional arthroplasty
Extensive resection of callus
Presence of dead space
Hematoma formation
Differentiation of local pluripotent stem cells to fibroblasts and
osteoblasts
Decrease in vascularity and pO ₂ favouring the change of fibrous
tissue to bone
OBJECTIVE : create the functional pseudoarthrosis to prevent
recurrence and provide joint mobility
46. Variations of TMF-
Feinbery & Larsen – Full thickness TMF+periosteum
Pogrel & Kaban – Fascia alone & inferior rotated over arch
at joint space
Omura & Pujita – Flaps fold over fascia- both condyle &
fossa surface
47. Other flaps-
Dermal grafts Masseter muscle grafts Auricular cartilage Full thickness skin graft
Fascia lata
Alloplasts - Proplat / teflon implants
Polyethylene condyle caps
Christensen metallic fossa implants
Silatic sheets
Acrylic marbles
48. Int. J. Oral Maxillofac . Surg. 2011; 40: 50-56 A.Thangavelu et al
55. Ankylosis surgery in child
POSNICK & GOLDSTEIN – Trauma was most common cause
Use of miniplates & screw to secure costochondal graft & early mobility
PENSLER ET AL – Beneficial to leave posterior open bite post op
56. COMPLICATIONS
Perforation into middle fossa Secure bleeding from infra temporal fossa
Costochondral over growth – use of 0.5-2cm dimensional chance of all cartilage bone
Scar formation
Facial nerve damage
Frey’s syndrome
EAM perforation
57. Re- ankylosis – young pt osteogenesis is high
CADCAM replacements in 2 stage procedure
1 st stage – Gap arthroplasty
2nd stage – Insertion of implants 10Gy fractioned in 5 doses
58. CONCLUSION
TMJ ankylosis is a challenging problem
Surgical correction is technically difficult and the incidence of recurrence after
treatment is high
59. References:
Peter wardbooth
Okeson-tmj Is aggressive gap arthroplasty essential in the managementof temporomandibular joint
ankylosis ?—a prospectiveclinical study of 15 cases
Lokesh - Lokesh Babua,e , Manoj Kumar Jainb ,∗, C. Rameshc,f , N. Vinayakad,g British Journal of Oral
and Maxillofacial Surgery xxx (2013) xxx–xxx 4.
Use of Human Amniotic Membrane as a Interpositional Material in Treatment of Temporomandibular
Joint Ankylosis - Umut Tuncel , MD,* and G. Y. Ozgenel , MD† 5. Intraoral approach for arthroplasty for
correction of TMJ ankylosis - E. C. Ko , M. Y. Chen, M. Hsu, E. Huang, S. Lai: Intraoral approach for
arthroplasty for correction of TMJ ankylosis . Int. J. Oral Maxillofac . Surg . 2009; 38: 1256–1262
