etiopathogenesis,classification,sawhney classification,clinical features,diagnosis,management,surgical aproaches,condylectomy,gap arthroplasty,interpositional arthroplasty,kaban's protocal,complications

1. TEMPOROMANDIBULAR JOINT
ANKYLOSIS
1
By:Prashanth sharma
Final year BDS

2. • Greek terminology meaning ‘stiff joint’.
• Fusion between cranium and condyle.
• Jaw function is affected.
• Hypomobility or immobility of joint can lead to inability to open
mouth from partial to complete.
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3. ETIOPATHOLOGY OF ANKYLOSIS OF TMJ
•
•
•
•
congenital
At birth (forceps delivery )
hemarthrosis
condylar # - intra / extra capsulra
Trauma
•
•
•
•
•
Parotitis
tonsilitis
Abscess around the joint
osteomyelitis of the jaw
actinomycosis
Infections
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4. Inflammation •
•
•
Rheumatoid arthritis
osteoarthritis
Septic arthritis
Systemic
diseases
•
•
•
•
•
small pox
scarlet fever
Scleroderma
beriberi
Ankylosing spondylitis
Other
causes
•
•
•
•
bifid condyle
prolonged trismus
prolonged immobilization
Burns
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5. Pathophysiology
Trauma
↓
Extravasation of blood into the joint space
↓
Heamarthrosis
↓
Period of restricted mobility due to pain
↓
Fibrosis leading to further restriction
↓
Gradual bone formation
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6. CLASSIFICATION
1. Based on the location:
-
-
Intra articular or true ankylosis
Extra articular or false ankylosis
2.
-
-
-
Based on the
Bony.
Fibrous.
Mixed.
type of tissue involved:
3. Based on the extent of fusion/severity of ankylosis:
-
-
Complete.
Incomplete.
4. Based on the side involved:
-
-
Unilateral.
Bilateral.
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7. SAWHNEY CLASSIFICATION
1. Type I: Head of the condyle is flattened or deformed with close
approximation to the upper
make movement possible.
articular surface. Dense fibrous adhesions
2. Type II: Head misshapen or flattened but is distinguishable. Bony
fusion of head to outer edge of articular surface.
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8. 3. Type III: Bony block seems to bridge across ramus and zygomatic
arch. Displaced condylar head. Elongation of coronoid process seen.
4. Type IV: Bony block is wide and deep and extends between ramus and
upper articular surface thereby completely replacing joint architecture.
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9. CLINICAL MANIFESTATIONS
→ Unilateral Ankylosis:
• Facial asymmetry.
• Deviation of mandible and chin on affected side.
• Roundness and fullness of face on affected side.
• Cross bite maybe seen.
• Lower border of mandible has a concavity on affected side.
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10. → Bilateral Ankylosis:
• Inability to open mouth progresses to decreased interincisal opening.
• Typical ‘bird face’ deformity with receding chin.
• Neck chin angle reduced or completely absent.
• Class II malocclusion.
• Protrusive upper incisors with anterior open bite.
• Multiple carious teeth with bad periodontal health.
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11. DIAGNOSIS
Diagnosis is based on the following:
1.
2.
3.
a.
History of trauma, infection etc.
Clinical findings.
Radiographic findings:
OPG: Shows both joints picture which can be compared in unilateral
cases.
Lateral oblique view: Gives anteroposterior dimension of condylarb.
mass. Elongation of coronoid process seen.
c. Cephalometric radiograph: Taken to evaluate associated skeletal
deformities.
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12. d. CT scan:
• Very helpful guide for surgery.
• Relation to middle cranial fossa, anteroposterior width can be
assessed.
• Any presence of fractured condylar head can be located.
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13. MANAGEMENT OF TMJ ANKYLOSIS
Aims and Objectives of Surgery:
1. Release the ankylosed mass and creation of a gap to mobilize
joint.
Creation of a functional joint.
the
2.
3.
4.
5.
6.
To
To
To
To
reconstruct the joint and restore vertical height
prevent recurrence.
restore normal facial growth pattern.
of ramus.
improve esthetics and rehabilitate the patient.
Surgical Techniques:
I: Condylectomy.
II: Gap Arthroplasty.
III: Interpositional Arthroplasty.
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14. Management:
Adult
• Cause:
• Cause:
• Trauma
• Aim:
• Restoration of
satisfactory
movement
• Trauma
•Infection
• Aim:
•Restoring
function and
movement
• Bony
replacement
with CCG
• Correction of
occlusal and
cosmetic
deformity
Childhood
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15. SURGICALAPPROACHES
Blair
inverted hockey stick vertical incision
Dingman
question markAl-Kayat & Bramley in 1979-
modified preauricular approach
and Ivy in 1936- Thoma in 1958- angulated Preauricular incision-
Popowich and Crane in 1982-
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16. Submandibular approach Postramal incision (Hinds) Endaural incision
Coronal approach Postauricular approach
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17. Condylectomy:
Advocated in cases of fibrous ankylosis, where joint space is
obilterated with deposition of fibrous bands but there is not much
deformity of condylar head.
• Preauricular approach used commonly, others include Al Kayat
Bramley, inverted hockey stick.
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18. Gap Arthroplasty:
• Section consists of two horizontal osteotomy cuts and removal of
bony wedge for creation of a gap.
• No substance is interposed between the two cut bony surfaces.
• Minimum gap of 1 cm to prevent reankylosis.
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19. Interpositional Arthroplasty:
• Involves creation of a gap, but in addition a barrier is inserted between
the cut bony surfaces to minimize risk of recurrence and to maintain
vertical height of ramus.
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19

20. 20

21. Materials used in Interpositional Arthroplasty:
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22. KABAN’S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS
1. Early surgical intervention.
2.
-
Aggressive resection:
Gap of at least 1 – 1.5 cm should be created.
3.
-
Ipsilateral coronoidectomy and temporalis myotomy:
After gap arthroplasty, coronoidectomy on the same side
carried out.
should be
- Temporalis muscle attachments are severed by carrying out temporalis
myotomy.
4. Contralateral coronoidectomy and temporalis myotomy.
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23. 5. Lining of glenoid fossa region with temporalis fascia.
6. Reconstruction of ramus with costochondral graft.
7. Early mobilization and aggressive physiotherapy for
months postoperatively.
at least six
8. Regular long term follow up.
9. To carry out cosmetic surgery at later date, when growth of patient is
completed.
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24. COMPLICATIONS DURING SURGERY
During Anesthesia:
a. As the patient cannot open the mouth, awake blind intubation has to
be done where co – operation is required which is difficult to achieve
sometimes.
b. Because of small mandible and altered position of larynx, intubation
poses a problem.
c. Aspiration of blood clot, tooth or foreign body during extubation.
d. Danger of falling back of tongue and obstructing airway is always
there after extubation.
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25. During Surgery:
a.
b.
c.
d.
e.
f.
Hemorrhage.
Damage
Damage
Damage
Damage
Damage
to
to
to
to
to
external auditory meatus.
zygomatic and temporal
auriculotemporal nerve.
parotid gland.
glenoid fossa.
branch of facial nerve.
During Postoperative Followup:
a.
b.
c.
Infection.
Open bite.
Recurrence of ankylosis.
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26. FREY SYNDROME:
1st described by frey.
It is localised gustatory sweating in the area supplied by
auriculotemporal nerve.
Cause:
Congenital or acquired
Surgery of parotid gland, TMJ , parotid abscess, facial wound.
Clinical feature:
Pain in area supplied by ATN
Gustatory sweating
Erythema & flushing
Positive iodine starch test
1.
2.
3.
4.
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27. 1.
2.
3.
4.
5.
i.
ii.
iii.
Treatment:
Antiperspirants
Anticholinergic prepn: glycopyrolate
Botulinum toxin A inj.
Radiation therapy: 50 Gy
Surgical:
Skin excision: for localise & small area
ATN section: not permanent
Tympanic neurectomy: safe procedure
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28. RECURRENCE OFANKYLOSIS
Several factors said to be responsible:
1.
2.
3.
Inadequate gap created between fragments.
Fracture of costochondral graft.
Loosening of costochondral graft due to inadequate
ramus.
Inadequate postoperative physiotherapy.
Inadequate coverage of glenoid fossa surface.
fixation to
4.
5.
6. Higher osteogenic potential and periosteal osteogenic
responsible for high rate of recurrence in children.
power maybe
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29. THANK YOU!
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