TMJ Ankylosis-Dr Stanley John

1. TMJ ANKYLOSIS
DR. STANLEY JOHN CHERIYAN
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS
• INTRODUCTION
• SURGICAL ANATOMY
• ETIOLOGY
• PATHOGENESIS
• CLASSIFICATION
• MANAGEMENT
• COMPLICATIONS
• REFERENCES

3. INTRODUCTION
• ankylosis is joining of bone resulting in immobility of a joint.
• Problems :
• Limited mouth opening and mastication
• Speech
• Facial growth asymmetries and mandibular deficiencies
• Airway compromise
• Dental care
• Psychological burden
• Reduced QOL

4. HISTORICAL PERSPECTIVES
• Burton in 1826 described the treatment of ankylosis by the formation of artificial
joints
• Verneuil in 1826 was the first to do gap arthroplasty
• Humphry performed first condylectomy for ankylosis in 1854
• In 1914, Murphy reported the use of autogenous graft as interposition material
after lysis of TMJ ankylosis
• In 1942, Pickerill propounded that the ankylosed TMJ should be reconstructed by
means of cartilage graft

5. • Gordon in 1955 used alloplastic material to replace TMJ disc after discectomy.
• Georgiade first described the use of the dermis as a disc replacement in 1957.
• Auricular cartilage as a replacement for the disc was introduced by Perko in
1973.
• In 1990 Kaban gave protocol for the management of ankylosis which was
modified in 2009.
• Wolford first used TMJ prosthesis in 1992

6. TMJ anatomy
• Synovial joint of condylar
variety

7. TMJ anatomy
• Bony
anatomy :
• Glenoid
fossa
• Condyle

8. TMJ anatomy
• Muscles :
• Masseter
• Lateral
pterygoid
• Medial
pterygoid
• Temporalis

9. TMJ anatomy
• Ligaments :
• Lateral/Temporomandibular
• Stylomandibular
• Sphenomandibular
• Fibrous capsule

10. TMJ anatomy

11. TMJ anatomy

12. Facial nerve & TMJ
• Distance from the lower point of
the external bony auditory canal
to the bifurcation: 1.3 to 2.8
• Posterior glenoid tubracle to the
bifurcation: 2.4 to 3.5 cm
• The most variable measurement
was the point at which the upper
trunk crosses the zygomatic
arch ranging from 0.8 to 3.5cm
to the most anterior portion of
the bony external auditory
canal.

13. TMJ anatomy
Anatomic Difference between adult and child TMJ
Adults Children
Thick Cortical bone Thin cortical bone
Neck is thin Neck Is thick reason y
condylar # is common
Anterior wall of auditory
meatus is composed of bone
Anterior wall of auditory
meatus is composed of
cartilage
Vestigeal , remnant in adults Presence of discomalleolar
ligament

14. Etiology of Ankylosis
Trauma
• At birth – forceps delivery
• Heamarthrosis
(direct/indirect trauma)
• Condylar fracture –
intracapsular/ extracapsular
• Glenoid fossa fracture ( rare )
Infections
• Otitis media
• Parotitis
• Furuncle
• Abscess around the
joint
• Osteomyelitis of the
jaw
• Actinomycosis

15. Inflammation
• Rheumatoid arthritis
• Osteoarthritis
• Septic arthritis –
hematogenous
spread
• Ankylosing
spondylitis
Rare causes
• Polyarthritis
• Measles
• Small pox
• Congenital AV
Malformations
Systemic
causes
• Scarlet fever
• Typhoid
• Beriberi
• Bifid condyle
• Prolonged trismus
• Prolonged
immobilization
• Idiopathic
• Burns
Other Causes

16. Etiology of pseudoankylosis
• Depressed zygomatic arch
• Fracture dislocation of
condyle
• Hypertrophy of coronoid
process
• Fibrosis of temporalis muscle
• Myositis ossificans
• Scar contracture
• Tumour of condyle or coronoid

17. Pathogenesis
• Trauma to the joint
• Intracapsular Hemarthrosis formation and
subsequent reorganization
• Prolonged immobilization
• Ossification
• Hypomobility

18. Pathogenesis
• Intracapsular hematoma ossification theory is
based on animal studies / surgically created
fracture
• Otzan et al proved that Intracapsular hematoma
formation is not enough for ankylosis formation
• Goss et al : if the disk is left in place and
undamaged , ankylosis didn’t occur
• Collection of blood , bone , cartilage fragments
leads to environment favoring ankylosis

19. Pathogenesis
• Laskin(1978) : contact between articular surface of
glenoid fossa and ramus was essential for ankylosis
• Rowe’s theory of burst condyle
Condylar head in younger person is not well
developed with wide neck and soft head
Less adapted to crushing injuries directed along its
long axis
Leads to burst condyle and Intracapsular hematoma
+bone fragments

20. Clinical manifestation and sequelae
• Decreased interincisal opening < 5 mm
• Inability to form oral seal
• Absent condylar movements
• Restricted mandibular growth
• Prominent antegonial notch
• Elongated coronoid
• Oral :
• Malocclusion
• Poor oral hygiene

21. Clinical manifestation and sequelae
• Unilateral cases :
• Chin deviation towards affected side
• Fullness on affected side , flattening on
contralateral side
• Shortened vertical height
• Deepened antegonial notch
• Deviation to opposite side on opening

22. Clinical manifestation and sequelae
• Bilateral cases :
• Retrognathic mandible
• Microgenia
• Bird facies / Andy gump
deformity
• Convex profile
• Short hyomental distance + tight
suprahyoid musculature
• Absent / deficient cervicomental
angle
• Open bite
• B/L posterior crossbite

23. Differential diagnosis :
• Depressed zygomatic arch fracture
• Adhesions of the coronoid process to zygoma
• Hypertrophy of the coronoid process
• Fibrosis of the temporalis muscle
• Myositis ossificans
• Scar contracture following thermal injury
• Tumor of the condyle or coronoid process

24. Radiographic assessment
• Panoramic radiograph :
• Hazy/complete bony obliteration of joint space
• Reduced vertical height of ramus
• Bulky coronoid
• Shallow sigmoid notch
• Lateral / anterior cephalogram :
• Shortened posterior facial height
• Steep occlusal and mandibular planes
• Retrognathia
• Retrogenia
• Airway narrowing

25. Radiographic assessment
• CT scan :
• Axial :
• mediolateral &
anteroposterior extent
• proximity with skull
base

26. Radiographic assessment
• CT scan :
• Coronal :
• Mushroom shaped
head
• Mediolateral extent
and level of inferior
cut
• Proximity to maxillary
artery
• Radiolucent area
inside the ankylotic
mass , represents
remanescent disk

27. Radiographic assessment
• CT scan :
• 3D CT:
• Elongated coronoid process
• shallow sigmoid notch
• Reduced vertical height
• Accentuated antegonial notch
• Mandibular asymmetry

28. Classification
• Kanjanian classification :
• True ankylosis
• False ankylosis
• Pseudo ankylosis

29. Classification
• Topazian classification :
• Stage I: ankylotic bone limited to the condylar process
• Stage II: ankylotic bone extending to the sigmoid notch
• Stage III: ankylotic bone extending to the coronoid process.

30. Classification
• Sawhneys classification :
• Type I :
• Flattened and deformed head
• Dense fibrous adhesions
• Probably due to a communited condylar head fracture

31. Classification
• Sawhneys classification :
• Type II :
• Misshaped head
• Bony fusion of head to articular surface in small area
• Upper articular surface and articular disk undamaged
• Communited fracture of head + partial damage to upper articular
surface

32. Classification
• Sawhneys classification :
• Type III:
• Bony block bridging ramus and Zygomatic arch
• Displaced head lying fused or free medially
• Severe fracture dislocation of head + laceration of capsular ligaments

33. Classification
• Sawhneys classification :
• Type IV:
• Wide and deep bony block extending from ramus to upper articular surface
completely
• Complete loss of joint architecture
• Fracture dislocation of head + injury to capsular ligaments , articular disk ,
upper articular surface .

34. Classification
• Radiographic classification : Hakim and Metwali
• Type-I: uni / bilateral fibrous ankylosis
• Type-II: uni /bilateral bony fusion with maxillary
artery at normal anatomic location and safe
distance from ankylotic chunk
• Type III: maxillary artery in close proximity to the
ankylotic chunk/ running through it
• Type IV: extensive ankylosis / fusion with skull base
proximity to other vital structures- carotid, jugular
foramina, foramen spinosum and pterygoid plates

35. Management
• Primary treatment goals :
• Resection of ankylosis and achieve normal mouth opening
• Restoration of function of TMJ
• Prevent reankylosis and
• Achieve symmetric mandibular / correct mandibular
asymmetry

36. Management
• Challenges :
• Anesthetic challenges
• Reankylosis
• Restoration of growth centre
• Correction of esthetics

37. Management
Approaches
• Pre-auricular
• Preauricular- hockey stick
• Al-kayat Bramley modification of pre-auricular
• Endaural
• Post-auricular
• Submandibular
• Rhytidectomy

38. Management
• Kaban’s protocol :
• Removal of the ankylotic chunk to create a gap of no less than 1.5 cm
• Ipsilateral coronoidectomy. After this resection the MIO Should be > 35 mm
• Contralateral coronoidectomy.
• Temporalis fascia flap and costochondral graft harvest.
• Rigid fixation of CCG
• MMF in prefabricated splint x 10 days
• Release of MMF and a strict protocol of physiotherapy

39. Management
• Modified Kaban’s protocol for pediatric patients :
• Aggressive excision of fibrous / bony mass
• Coronoidectomy on ipsilateral side
• Coronoidectomy on opposite side if step 1 and 2 do not result in
MIO of > 35 mm or dislocation of opposite side
• Lining of joint with temporalis fascia or native disc
• Reconstruction of with DO or CCG and rigid fixation
• Early mobilization
• Aggressive physiotherapy

40. Management
• Treatment philosophies:
• Gap arthroplasty
• Interpositional arthroplasty
• TMJ Reconstruction

41. Gap arthroplasty
• Verneuil in 1826 was the first to do gap arthroplasty.
• The ankylotic mass is shaved to a flat ramus surface.
• If we find a cleavage line, it is used as the superior bony cut plane.
• If there is no cleavage line, an imaginary line through the lower border of the zygomatic
arch is considered.

43. Advantages
• Simple procedure
• Short operating time
Disadvantages
• Pseudo-articulation
• Short ramus height
• Failure to remove all bony
disease
• Development of open bite
• Recurrent ankylosis (60%)
.

44. Inter positional arthroplasty
• First introduced by Verneuil in 1860
• It minimizes reduction in the vertical
height of ramus and reduces the risk
of relapse and malocclusion

45. Interpositionalmaterials
Autogenous Allogenous Alloplastic
Costochondral graft Chromatized submucosa of
pig bladder
Metallic-
tantalum foil/ plate
Metatarsal bone grafts Lyophilized bovine
cartilage
316L stainless steel
Sternoclavicular graft Titanium
Auricular cartilage Gold
Temporal fascia Nonmetallic
Fascia lata Silastic
Dermis of Temporalis
muscle
Teflon
Acrylic
Nylon
Proplast
Ceramic implants

46. Ideal requisites of interpositional materials
• Cost effective
• Cosmetic consequences of harvesting should be
minimal
• Stable under masticatory force
• Minimal risk of infection
• Prevent recurrence caused by heterotrophic
calcification

47. Disadvantages of interpositional materials
Alloplastic materials
• Foreign body reaction
• Instability
• Infection
• Extrusion
Autogenous materials
• All have some donor site morbidity
• Muscle flaps tend to contract and become fibrous
• Cartilage may calcify
• Thin grafts such as skin, dermis and auricular cartilage may not maintain the height of
the ramus adequately, and may perforate under pressure from the condyle

48. Management
Temporalis myofascial flap
Inferiorly pedicled flap based on middle
temporal and deep temporal artery
Proximity
Good blood supply
Vague similarity to disc

49. Management
Modification of
temporalis flap :
Fascia facing
both surfaces
Increased bulk
Less open bite
Less chance of
temporalis
muscle
degeneration

51.  An L-osteotomy is used to create the transport disc.
 The vertical limb of the “L” parallels the vector that will take
the disc into the glenoid fossa.
 The superior portion of the disc is rounded to make a
new articular surface.
 A small portion of the osteotomy is left incomplete to
stabilize the disc during placement of the distractor.
 The vascular attachments on the medial aspect of the disc
are maintained.
Distraction Osteogenesis for TMJ Reconstruction

52.  A distractor length ranged between 13 and
30 mm is used.
 Attachment plates are chosen and trimmed
according to the anatomy. At least 3 screws
are placed in each plate.
 The dead space is filled with a fat graft (left)
or temporalis flap, to inhibit heterotopic bone
formation.

53.  The distraction rod is brought through the skin of
the neck through a separate stab incision.
 After a latency period of 7 days, distraction of 0.5
mm is carried out twice daily.
 Mobilization is begun immediately and
maintained throughout distraction.

54. After 3 months, the distractor
is
removed through the
same
submandibular incision. The
superior attachment plate has
moved far from the incision and is
left in place. Callus
in the distraction gap has
formed
woven bone, which is remodelling
into solid lamellar bone.
Distraction is discontinued when
the
occlusion reaches the
desired position.
Overcorrection may
be
used. The activation rod is
removed or cut short below the
skin. The distractor acts as a rigid
fixator while
callus produces new bone in the
distraction
gap.

55. Advantages
Eliminates donor sitemorbidity
Relapserate is much less
Earlymobilization
Disadvantages
Additional operations might be necessary to
correct any residual asymmetry after the end of
growth
Allows immediate mobilization of thejaw
Duration islonger
Patientscompliance
Device failure
Infection

56. Buccal fat pad
Advantages
• Less chance of resorption
• Good long term
interpositional material

57. Coronoid process
• In patients with ankylosis of the TMJ the coronoid is thicker than the normal
one, so it can provide sufficient strength for loading of the TMJ after condylar
replacement.
• Avoids a second surgical site and the related donor-site complications, which
facilitated the operation and reduced the intervention.
• Less resorption

58. A: The coronoid process prepared for grafting. B: The use of native articular
disc as an interpositional tissue (arrow). C: The fixation of coronoid process.

59. Fat Graft
incision for harvest of
(A) Marked
periumbilic
al abdominal fat
graft.
(B) Undermining of skin and fat before
harvest.
circumferenti
al
(C)Composite harvest of abdominal
fat.
(D)Exposure of graft site for
augmentation of fat graft.
(E) Adaptation of fat graft before
closure

60. Indomethacin
• Indomethacin is a non-selective inhibitor of cyclooxygenase (COX) 1 and 2, enzymes that
participate in
prostaglandin synthesis from arachidonic acid.
• Indomethacin is used most commonly for the treatment of
inflammation and pain resulting from rheumatic disease.
• Orthopaedic surgeons have been using Indomethacin to prevent the formation of heterotopic
bone after
hip replacement surgery.
• Studies have demonstrated that Indomethacin is a potent inhibitor of local remodelling and repair
of bone after trauma.
• Initial results for the long term use of Indomethacin have been favourable, providing a solution for
many patients however further research is warranted

61. TMJ RECONSTRUCTION
• Goals
• Restoration of normal joint function
• Restoration normal posterior vertical dimensions and length
• Stable skeletal occlusal relationship
• Maintenance of facial symmetry
• Lifetime maintenance of restored function, comfort and
esthetics

62. Autogenous TMJ replacement
• 1909 – Bardenheur - replaced condyle - 4th metatarsal
• 1920 - Gillies used costochondral graft
Donor site alternatives
Ramus condylar unit Glenoid fossa lining
• Costochondral graft
• Metatarsal graft
• Sternoclavicular joint graft
• Fibula graft
• Iliac graft
• Dermis graft
• Auricular cartilage graft
• Temporalis myofascial flap

63. RESECTED SEGMENT AS AUTOGRAFT
• R. Gunaseelan has used the resected segment as
an autograft after recontouring, in extensive
ankylosis of temporo mandiblular joint.
• The graft is rotated 90°s, so that the cortical
surface faces the temporal bone
65

64. CCG

65. CC
G
Advantages:
• Most widely used
• Has a cartilage cap, mimicking both
the bone and cartilaginous
components
• Has intrinsic growth potential
• Easy accessibility and adaptation
• Gross anatomical similarity to
the mandibular condyle
Limitations:
• Unpredictable growth
• Poor bone quality
• Possible separation of cartilage from bone
Donor-site
complications:
• Pleural tear
• Pneumothorax
• Pleural effusion

66. Sternoclavicular
Advantages
Similar anatomical and
physiological
characteristics.
Consists of a cartilaginous
cap.
Option for a whole joint
graft.
Has the potential for
growth.
Probability of regeneration
at donor site
Donor site
complications:
Damage to the great
vessels.
Instability of the clavicle
under stress with
resulting shoulder
instability.
Clavicle
fracture.

67. Metatarsal
Advantages:
Combination of articular cartilage
and
bone.
Fitting anatomy because of small
size.
Has potential for growth.
Donor-site
complications:
Aesthetic loss of a toe.
MTP joint being a simple hinge joint
does not follow the same movements
as the TMJ

68. Alloplastic joint replacements
• 1840– John Murray treated ankylosis - wood block
• 1890– Gluck - ivory prosthesis
• 1933 – Risdon – gold foil
• 1947 – Goodsell - titanium foil
• Total joint - Kent-Vitek prosthesis in 1970
• Christensen – 1964 - lined glenoid fossa —
vitallium
• Chase – 1995 - chromium cobalt head

69. Protocol for joint replacement
• Release the ankylosed joint.
• Remove the heterotopic and reactive bone with thorough debridement.
• Reconstruct the TMJ with a total joint prosthesis.
• Pack a fat graft around the articulation area of the prosthesis.
• Perform indicated orthognathic surgery in a single surgery.

70. Indications
• Ankylosed, degenerated or resorbed joints with severe anatomic
discrepancies.
• Failed autogenous bone grafts.
• Recurrent ankylosis

71. Relative contraindications
• Patient age
• Lack of understanding of the
patient
• Uncontrolled systemic disease
• Allergic to materials used in devices
• Active infection at implantation site

72. Advantages
• Physical therapy can begin immediately.
• No need for second donor site.
• Reduced surgical time.
• Alloplasts – mimic normal anatomic contours, better adapted to the bony surfaces.
• Stable occlusion post-operatively.
• Decreased hospital stay.
• Opportunity to manipulate prosthesis design to discourage heterotrophic bone formation

73. Disadvantages
• Cost of prosthesis
• Material wear and failure
• Long term stability
• Inability to follow patients growth
• Potential for severe giant cell reactions
• Fit limitations of stock prosthesis

74. Alloplastic TMJ prosthesis
• Fossa prosthesis
• Condylar prosthesis
• Total joint
prosthesis
• Kent- Viket
• Synthes
• Delrin -Timesh
• Christensen
• Biomet Lorenz

75. Biomet Lorenz Prosthesis
• The mandibular component is manufactured from Co-Cr alloy with a roughened
titanium plasma coating on the host bone side of the ramal plate
• The condylar component is secured to the ramus with self retaining, cross drive 2.7-
mm self-tapping bone screws made of titanium alloy
• The ramus of the mandibular component is currently manufactured in lengths of 45
mm, 50 mm, and 55 mm
• The fossacomponent is manufactured from a specific grade of ultrahigh molecular
weight polyethylene called Arcom manufactured by Biomet.
• The fossa is fixed to the zygomatic arch with self-retaining, self tapping 2-mm screws

76. Lorenz Prosthesis

77. Kent-Vitek Total Prosthesis
• In the early 1970s Kent and colleagues developed a
glenoid fossa prosthesis
• The original VK-1 fossa had an articulating surface
composed of poly tetrafluoro ethylene (PTFE).
• The fossa was revised and called the VK-2 fossa, and its
articulating surface was composed of ultra-high molecular
- weight polyethylene (UHM-WPE) .
• The flange of the prosthesis was secured to the zygomatic
arch with screws.
• The condylar prosthesis was constructed of chromium
cobalt with a layer of Proplast on the inner surface of the
ramal flange to encourage rapid ingrowth of both hard and
soft tissues
• Complications included glenoid fossa resorption,
especially in patients who had undergone ramal

78. Christensen
• The Christensen TMJ fossa eminence prosthesis
(FEP) is designed to be used alone as a partial
joint for treatment of
• Severe internal derangement
• Adhesions
• Disc perforation
• Ankylosis
• The condylar prosthesis is always used in
conjunction with a FEP and constitutes a total
joint replacement.

79. • IPG results in a significant improvement in MIO and lower
recurrence rate when compared to GA.
• IPG also shows a greater improvement in MIO and
comparable recurrence rate when compared to CCG
reconstruction.
• GA and CCG reconstruction have a comparable recurrence
rate.
CCJ provides greater MIO when compared to AJR, whereas
AJR is superior to CCJ in reducing pain
83

80. • Costochondral graft is preferred by surgeons, but distraction
osteogenesis is slowly gaining popularity and may ultimately
become the standard procedure.
• Tissue engineering is a budding field which has shown
promising results in animal studies but has not been applied
to humans.
• To date, there is no ideal autogenous graft for condylar
reconstruction that satisfies the complex anatomy and the
myriad of functions of a missing condyle.
84

81. Complications of TMJ surgery
Intra op
• Hemorrhage
• Damage to external acoustic
meatus
• Parotid gland fistula
• Damage to auriculotemporal nerve
• Damage to zygomatic and temporal
branch of facial nerve

82. Post op
• Transient facial nerve weakness
• Infection
• Auriculotemporal nerve injury- Frey’s
syndrome

83. Long term complication
• Partial graft resorption
• Loose hardware
• Facial scarring
• Condylar overgrowth
• Limited mouth
opening
• Reankylosis

84. References :
• Maxillofacial surgery vol II : Peter ward booth
• Principles of oral and maxillofacial surgery : Peterson
• Ahmed; Conservative gap arthroplasty in temporomandibularankylosis not
involving the sigmoid notch:a selected age group
study; British Journal of Oral and Maxillofacial Surgery (2016) 1–6
• Junli Ma et al; Interpositional arthroplasty versus reconstruction arthroplasty for
tmj ankylosis: A systematic review and meta-analysis; J of Cranio-Maxillo-Facial
Surgery 43 (2015) 1202e1207
• Lokesh Babu et al; Is aggressive gap arthroplasty essential in the management of
tmj ankylosis?—a prospective clinical study of 15 cases; BJOMS 51 (2013) 473–
478

85. • K. Su-Gwan: Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int.
J. Oral Maxillofac. Surg. 2001; 30: 189–193.
• Harry C. Schwartz, and Robert J. Relle, Distraction Osteogenesis for Temporomandibular Joint
Reconstruction J Oral Maxillofac Surg 66:718-723, 2008
• Zhu et al; Free grafting of autogenous coronoid process for condylar reconstruction in patients with
temporomandibular joint Ankylosis; (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:662-7)
• Reza Movahed et al, Management of Temporomandibular Joint Ankylosis; Oral Maxillofacial Surg Clin N
Am 27 (2015)
• 27–35
• Wolford et al; Temporomandibular Joint Ankylosis Can Be Successfully Treated With TMJ Concepts
Patient-Fitted Total Joint Prosthesis and Autogenous Fat Grafts; j.joms.2016.01.017
• muralee mohan et al; reconstruction of condyle following surgical correction of temporomandibular
joint ankylosis: current concepts and considerations for the future; nujhs vol. 4, no.2, june 2014, issn
2249- 7110

86. THANK YOU