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Hypermobility and ankylosis

  1. Temporomandibular Joint: Hypermobility and Ankylosis Hanan Shanab- SBOMFS-R4 99 Chapter
  2. ETIOPATHOGENESIS • HYPERMOBILITY • Subluxation • Dislocation . • Recurrent joint dislocation is associated with severe pain and loss of function.
  3. 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.
  4. DIAGNOSTIC STUDIES HYPERMOBILITY Clinically: •the patient has anterior open bite of several centimeters • Palpable depression immediately in front of the tragus (empty glenoid fossa).
  5. 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.
  7. 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.
  8. 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.
  9. 1- Create a mechanical obstruction
  10. 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.
  11. 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.
  12. 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.
  13. 2- Arthroplasty
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 3- remove the obstruction Eminectomy
  20. 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.
  21. 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.
  23. 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.
  24. 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
  26. 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 .
  27. 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,
  28. Classification of ANKYLOSIS
  29. 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
  30. 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
  31. 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.
  32. 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
  33. Radiographic features •Widening of the ramus
  34. treatment
  35. 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.
  36. 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
  37. 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
  38. 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
  39. •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.
  40. 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.
  41. 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.
  42. 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
  43. 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
  44. 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.
  45. 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.
  46. 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.
  47. 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
  48. 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.
  49. 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.
  50. 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..
  51. 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 .
  52. 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.
  53. 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.
  54. Thank you

Editor's Notes

  1. The point at which excessive joint mobility becomes problematic is typically when it leads to recurrent joint dislocation.
  2. Internalderangement may also be associated with hypermobility, but the association between the two is not clearly understood
  3. The primary objective is to decrease joint translation and prevent subluxation and dislocation. Normal rotation within the joint should be maintained, but excessive movement of the condyle anterior to the articular eminence must be prevented.
  4. Multiple different approaches to prevent recurrent dislocation have been described.
  5. displace the root of the zygoma inferiorly and medially with an orthognathic forked nasal septum osteotome. The inferior aspect of the osteotomy should be just anterior to the apex of the articular eminence. ==The condyle must not be able to translate past the apex of the articular eminence at the completion of this procedure.
  6. Wilkes retractor is activated and the joint distended.
  7. The disc should be able to be passively repositioned. Disc plication (suture line, long white arrow; disc, arrow head; condyle, short white arrow).
  8. On the rare occasion when a
  9. advantage to limiting activity after the first 3 weeks, during which time adequate soft tissue healing and scarring will have occurred This is critical when arthroplasty or eminectomy but less important for extra-articular procedures
  10. if surgery was bilateral. All of these exercises should be repeated at least six times a day.
  11. ==It is a serious and disabling condition that may cause problems in mastication, digestion, speech, appearance, and hygiene.
  12. Literature classifies ankylosis as true and false. Any condition that gives rise to osseous or fibrous adhesion between the surfaces of the temporo-mandibular joint is a true ankylosis. False ankylosis results from pathologic conditions not directly related to the joint.
  13. ==It is a serious and disabling condition that may cause problems in mastication, digestion, speech, appearance, and hygiene.
  14. The joint anatomy with ankylosis is different from that of a normal joint. Even though the joint capsule and extracapsular ligaments may be present and appear normal The intraarticular structures are radically altered.
  15. A multitude of different autologous tissues, including cartilage, fat, dermis, and temporalis muscle, can be interposed. This author prefers lysis and discectomy alone or the use of a temporalis muscle fascia flap.
  16. It is a challenging procedures. ==The gap arthroplasty is a procedure that creates a new area of articulation distal to the fused TMJ and ankylotic segment. ==The author prefers temporalis fascia/muscle because it is located within the surgical field and is easily harvested and transferred to the surgical site.
  17. the choice of interpositional material is a little more controversial.
  18. Although close proximity of the middle meningeal artery , internal jugular vein, and internal carotid artery to the medial lip of the normal glenoid fossa has been reported, the altered ankylosis frequently results in muscle fibrosis and coronoid hyperplasia.
  19. ==Because complete resection of the ankylotic mass frequently results in substantial loss of ramus height, This does not preclude use of the temporalis fascia/==muscle flap, which is vascularized by anterior and posterior deep temporal arteries. completely cover the mandibular neo-condyle. The use of several 5-0 Vicryl sutures swinging the muscle/fascia flap deep to the zygomatic arch ==and anterior to the articular eminence.
  20. replacement in patients with ankylosis may be performed as a oneor two-stage surgery. As surgeon experience increases, more cases can be done in one stage.== The 3D nature of the ankylosis and the occlusion can readily be assessed.
  21. critical size” defect, which reduces the likelihood for subsequent recurrent ankylosis.
  22. The author prefers this approach rather than a transparotid or submandibular approach, both of which tend to be associated with a greater risk for facial nerve injury. This dissection is carried behind the parotid gland anterior to the sternocleidomastoid muscle.
  23. Dissection proceeds easily to the level of the posterior belly of the digastric muscle, which defines the medial extent of the dissection. In so doing,