Temporomandibular Joint:
Hypermobility and Ankylosis
Hanan Shanab- SBOMFS-R4
99
Chapter

ETIOPATHOGENESIS
• HYPERMOBILITY
• Subluxation
• Dislocation .
• Recurrent joint dislocation is associated with severe
pain and loss of function.

PATHOLOGIC ANATOMY
Hypermobility:
•lateral TMJ ligament,and retrodiscal tissue may be lax and allow
excessive condylar movement anterior to the articular eminence.
•Patients with subluxation and dislocation is a relatively small
articular eminence.

DIAGNOSTIC STUDIES
HYPERMOBILITY
Clinically:
•the patient has anterior open bite of several centimeters
• Palpable depression immediately in front of the tragus (empty glenoid
fossa).

DIAGNOSTIC STUDIES
Radiographically:
OPG:
•The condyle anterior to the articular eminence in the infratemporal
fossa.
•Used to confirm adequate reduction of the dislocation.
CT:
MRI:
• will provide soft tissue imaging that allows the magnitude of joint
translation and disc position to be seen.
•it has little to offer in the acute setting.

TREATMENT

HYPERMOBILITY
Recurrent dislocation can be treated according to one of three
basic philosophies:
1-First:
to provide a mechanical barrier to joint translation through
bony augmentation of the articular eminence or down-
fracture of the root of the zygomatic bone (Dautrey
procedure).
2- The second philosophy :
•Eliminates the mechanical barrier to relocating the
condyle when it translates past the articular eminence by
an eminectomy.
•Lateral pterygoid myotomy.

The third philosophy:
also reduces joint translation but through plication..
-Intra-articular injection to create excessive fibrous tissue :
• sclerosing agents such as sodium tetradecyl sulfate and
sodium morrhuate
•Autologous blood
-arthroscopic scarification of the capsule, retrodiscal tissue, and
disc with the use of sclerosing agents, cautery, and laser has
been reported. These techniques are difficult.

1- Create a mechanical
obstruction

The Dautrey procedure (Le
Clerc)
•is a simple extra-articular surgical procedure.
•Indicated for
patients who have no symptoms of intra-articular
pathology.
•Disadvantage:
•bone remodeling and the potential for recurrent
dislocation.

The Dautrey procedure (Le
Clerc)
•Technique:
•A standard preauricular incision
•Subperiosteal dissection to expose
the lateral aspect of the articular
eminence and root of the zygoma.
•A periosteal elevator is then used to
elevate only the most inferior aspect of
the temporalis muscle medial to the
root of the zygoma.

The Dautrey procedure (Le
Clerc)
•The same elevator is then passed deep
to the root of the zygoma just into the
infratemporal fossa to protect the soft
tissues.
•A reciprocating saw is used to
osteotomize the root of the zygoma in an
oblique manner from post. to ant.
•The displaced zygoma usually
maintains its new position without any
fixation.

2- Arthroplasty

Arthroplasty
Indication:
•intra-articular pathology in addition to hypermobility.
•patients with symptomatic internal derangement and
recurrent dislocation.
•The internal derangement should be confirmed with
MRI before the surgical procedure.

Procedure of arthroplasty
•After exposing the joint.
•Placement of 0.054 Kirschner wires in the lateral aspect of the
articular eminence and neck of the condyl.
•incision 2 mm below the the fossa accessing the superior joint
space. Then to the inferior joint space by incising vertically
through the joint capsule and horizontally through the lateral
collateral check ligament. The disc can then be mobilized with a
periosteal elevator.
•The most frequent location of adhesions:
•within the superior joint space are often the anterior slope of
the eminence or the lateral aspect of the eminence.
• within the inferior joint space is the medial pole.

Procedure of arthroplasty
•adequate disc mobility must be achieved.
• The redundant retrodiscal tissue can then be assessed and excised
with tenotomy scissors, and
•plication of the disc to the retrodiscal tissue is begun medially (mini–
bone anchor), several 5-0 Vicryl sutures (Ethicon, Inc., New
Jersey) sutures are placed through the posterior aspect of the disc
and the retrodiscal tissue.

Procedure of arthroplasty
•perforation is present, there may be insufficient tissue to plicate the
•disc.
• Retrodiscal tissue can he horizontally divided as far as the tympanic
plate to transect the vertical collagen fibers & allows greater forward
movement of the tissue.
•Plication:
•1- may require a double-layered closure, one for the superior
lamina and one for the inferior lamina of the retrodiscal tissue.
•2-Retrodiscal tissue can be elevated off the tympanic plate and
pedicled inferiorly closed as single-layered.

Procedure of arthroplasty
•Lateral plication is performed by attaching the lateral aspect
of the disc to the inferior/lateral joint capsule. Three or four horizontal
mattress sutures using 4-0 Vicryl are placed in this fashion.
The Wilkes retractor is then closed and the lateral aspect of the
superior joint space closed with similar suture material. Subsequent
to the plication, only a limited degree of joint translation should be
possible.

3- remove the obstruction
Eminectomy

Eminectomy
is a procedure that eliminates the articular eminence.
It can be combined with arthroplasty,(rare)
•useful when other surgical procedures have failed.
•Technique:
•Entry is made into the superior joint space. A combination of
fissure burrs, osteotomes, or a reciprocation rasp can be used to
remove the inferior aspect of the articular eminence.

Procedure of Eminectomy
•During eminectomy the medial soft tissues envelope should not be
breached because of the potential for substantial bleeding.
• A reciprocating rasp or bone file can then be used to smooth the residual
articular eminence.
•Irrigation
•Closure of the superior joint space
•At the completion of the procedure the condyle should be manipulated &
move freely without restriction.

POSTOPERATIVE CARE

POSTOPERATIVE CARE
•In the 1st 3 weeks Patient should be instructed
to limit opening while eating and yawning.
•Beginning in the 4th week encourage physical
activity to prevent excessive fibrosis and limited
opening.
•The use of moist heat and non-steroidal
antiinflammatory medication before physical
therapy can be a tremendous advantage.

POSTOPERATIVE CARE
•Patients should open maximally by using the
thumb and middle finger on the incisal edges of
the anterior teeth to stretch, and this position
should be held for 10 seconds.
•repeated 10 times.
• Lateral excursive movements should also be
performed.
•The exercise should be performed bilaterally

ANKYLOSIS

ANKYLOSIS
•Ankylosis is a Greek terminology meaning 'stiff joint’. It can be
defined as "inability to open mouth due to either a fibrous or bony union
between the head of the condyle and the glenoid fossa".
•It can also causes disturbances of facial and mandibular growth, and
acute compromise of the airway invariably resulting in physical and
psychological disability
.

DIAGNOSTIC STUDIES
Clinically Radiographicaly
Fibrous Ankylosis: • Limited MIO and,
•when unilateral, reduced
lateral excursion toward the
unaffected side.
no significant finding
Bony Ankylosis: •no incisal opening
•no lateral excursions.
OPG:
•heterotopic bone
formation and no joint
space
CT:
• best imaged with axial
and coronal &(3D)
reconstructed
images provide the most
detail. For all but the most
simple bony
ankyloses,

Classification of ANKYLOSIS

Type I – decreased joint space with dense fibrous adhesion
(The condyle is present and there are only fibrous
adhesions)
Type II –decreased joint space with dense fibrous adhesion , which
also exhibits lateral lipping and bony bridge.
(There is bone fusion, the condyle is remodeled, and the
medial pole is intact)
Type III – broad bony bridging from the lateral ramus to the zygomatic
arch .
(There is an ankylotic block, the mandibular ramus is fused to
the zygomatic arch, the medial pole remains intact)
Type IV - complete bony fusion.
Sawhney classification

Stage I Ankylotic bone limited to condylar
process.
Stage II – ankylotic bone reach the sigmoid
notch .
Stage III - ankylosis extends to the coronoid
process.
Topazian Classification

Clinical picture
• Restricted mouth open and its associated sequelae including poor
oral hygiene and caries.
• Facial asymmetry
• Mandibular micrognathia and bird face deformity
• Class II malocclusion with posterior cross bite / anterior open bite.

Radiographic features
•After inability to open the
mouth ,repetitive isometric
contraction of the temporalis
muscle can lead to muscle
hypertrophy and subsequent
elongation of the coronoid
process
•Repetitive isometric contraction
of the massetric muscle can lead
to muscle hypertrophy and
subsequent accentuation of
antigonial noutch.
•Union between the head of the
condyle and the glenoid
• fossa

Radiographic features
•Widening of the ramus

treatment

Treating of fibrous ankylosis
•Fibrous ankylosis of the TMJ can generally be treated more
conservatively than bony ankylosis.
•depend on:
• the degree of fibrosis and the residual anatomy of the joint.
•This is often determined by the degree of movement possible on
clinical examination,
•the number of previous joint procedures.
•findings on CT.

Treating of fibrous ankylosis
•Accessing intracapsular,,,
•The degree of fibrosis is often variable.
•It may be possible to explore the superior& inferior joint space
and lyse the adhesions and fibrosis.
•Evaluate the disc for plication or discectomy with interpositional
graft.
•Postoperative physical therapy is crucial to help prevent
recurrence

Treatment of BONY ankylosis
1- Gap arthroplasty with /out
reconstruction with autogenous or
alloplastic material.
Disadvantages
Generating a pseudo-articulation,
shortening of the mandibular ramus and ,
Increase the risk of recurrence

Complications:
•The development of an open-bite in bilateral cases.
•Premature occlusion on the affected side with
contralateral open bite in unilateral cases.
•limited mouth opening post-operatively are possible

•autogenous tissue
•possible recurrent ankylosis at a rate that may be as high as
20-30%
•first episode of ankylosis.
•Pediatric patients,
•Fascia lata,dermis, cartilage, fat, and temporalis
fascia/muscle have all been used.

Treatment of BONY ankylosis
2-total joint replacement
•For recurrent ankylosis.
•Aggressive postoperative physical therapy is the key to reduce this risk
for recurrent ankylosis.
Costochondral grafts have the potential to provide additional growth.
The supplementary use of low-dose radiation (10 cGy) has been
shown to reduce heterotopic bone formation and may be considered
in the postoperative period in patients reconstructed with autogenous
tissue.

Technique of Gap arthroplasty
Kaban protocol:
1-Wide intraoperative exposure is required, bony, fibrous, and
granulation tissue are completely removed
•A 703 fissure burr is then used to remove2 mm of bone progressing in a
lateral to medial direction at the cleavage plane between the original
condyle and glenoid fossa or more inferior than the original location of
the glenoid fossa.
•The medial extent of the bony ankylosis should not be breached with
the burr & final separation of the bone is best achieved
with a twist osteotome.

Technique of Gap
arthroplasty
2- Dissection and stripping of the temporalis, masseter, and medial
pterygoid muscles followed by ipsilateral coronoidectomy are
performed in all cases.
3- After this resection is completed, the MIO is measured. If it is found
to be < 35 mm, contralateral coronoidectomy is performed via an
intraoral approach to attain the desired level of opening

Technique of Gap
arthroplasty
4-subsequent reconstruction must address this fact and attempt to restore
occlusion as well as function.
A-temporalis muscle/fascia flap is harvested as a full-thickness flap,
•teeth are placed into a prefabricated occlusal splint.
•MMF for 10 days
•after release a strict protocol of physiotherapy is employed

Technique of Gap
arthroplasty
• B- If costochondral reconstruction is planned, removal
of more bone (2 cm below the first cut)
• This is usually combined with a temporalis muscle/fascia
flap.

Technique of Gap
arthroplasty
C- Total joint replacement.
•For recurrent ankylosis and most non-pediatric pt.
• Advantages..
•include early function and a reduced frequency of recurrent ankylosis.
•Disadvantages.. include the potential need to replace the joints
throughout the life of the patient.

Total joint replacement
•Stock prostheses (Biomet Microfixation, Jacksonville, Fla) or
•custom-fit joints (TMJ Concepts, Ventura, Calif) are available. Total
joint
Technique:
1- 3D model must be constructed from a standard CT scan.
Gap arthroplasty should be performed on the model and then the
mandible repositioned to create the desired occlusion.

Total joint replacement
2- Awake fiberoptic intubation or awake tracheostomy.
3- Ivy loops, arch bars, or skeletal wires should then be placed.
4- A standard preauricular approach will provide adequate
access to the ankylosis.
5- 2 osteotomies done-the second is 2 cm inferior to the 1st and
creation of a “critical size” gap.
6-Coronoidectomies

Total joint replacement
•7- total joint replacement
A- If two-stage surgery is
•Place additional sterile towels over the surgical sites.
•the mandible should be placed in the correct occlusion and
secured with (MMF).
•Before returning to the surgical field, the surgeon should
place a towel, OpSite, or other sterile drape to cover the oral
cavity, as well as change gloves.
• The previous gap arthroplasty sites should be inspected for
smooth line angles and hemostasis.
• A Silastic block can then be carved to fill the gap and placed
to maintain space.
• wound can then be closed and the patient left in MMF.

Total joint replacement
•A postoperative CT scan. A 3D model will be made & a custom TMJ
prosthesis made.
•A second surgical procedure should be planned in 5 or 6 weeks
•Stage II surgery
•begins with release of the MMF.
•fiberoptic intubation
•A standard preauricular approach
•Silastic block which is easily removed.
•any immature granulation tissue can be removed.
•retromandibular incision.

Total joint replacement
•the parotid gland and branches of the facial nerve are swept forward
and superiorly.
•Subperiosteal dissection from the angel to the ramus
•The fossa and ramus prosthesis may be soaked in a topical antibacterial
solution prior to insertion.
•Placing the patient back in MMF
• attention can then be directed to the preauricular incision placing of
the fossa & fixation by 2mm screws..

Total joint replacement
•Retromandibular incision. The ramal/condylar
component is positioned carefulyl to ensure that the
condyle is seated in the most posterosuperior
position within the fossa.
•The component is then secured
with bicortical 2-mm screws.
This requires a preoperative 3D stereolithographic
model for planning .

Total joint replacement
•Stock prostheses require a relatively normalanatomy so that the
fossa and condyle components fit appropriately.
•When the anatomy is severely altered, a better choice is a custom-fit
joint.
•The potential use of autologous fat should be considered if concern
for heterotopic bone formation and recurrent ankylosis is great.
•The fat is easily harvested from the abdomen and packed around
the condyle.
•The wounds are then closed in standard fashion.

Post op care
•physical therapy regimen following release of ankylosis is
important(minimum of 3 months) .
•Good analgesics.
• Several devices have been manufactured to assist patients with
physical therapy.
•All rely on patient compliance (pediatric population).
• TheraBite (Atos Medical, Inc., West Allis, Wisc.)
•Dynasplint (Dynasplint, Severna Park, Maryland)
•Tongue blades.

Thank you