Description and management in details

1. TEMPOROMANDIBULAR
JOINT ANKYLOSIS AND
ITS MANAGEMENT

2. •INTRODUCTION
•CLASSIFICATION
•INCIDENCE
•AETIOLOGY
•PATHOPHYSIOLOGY
•CLINICAL FEATURES
•SEQUELAE OF TMJ ANKYLOSIS
•MANAGEMENT

3. Ankylosis (joint stiffness)
is the pathological fusion of parts of a joint resulting in restricted
movement across the joint
Ankylosis of the Temporomandibular joint, an arthrogenic
disorder of the TMJ, refers to restricted mandibular movements
(hypomobility) with deviation to the affected side on opening of
the mouth.

4. INCIDENCE
•Affects all age group but more in the first decade of life (0 – 10
years)
•There’s equal male and female distribution
•More common in Asian subcontinent

5. CLASSIFICATIONS
•Bilateral or Unilateral ankylosis
•Fibrous ankylosis or Bony ankylosis
•Intra-articular or Extra-articular ankylosis
•Complete or Partial ankylosis
•True or false ankylosis

6. AETIOLOGY
Trauma
-At birth (with forceps)
-Blow to the chin (causing
haemarthrosis)
-Condylar fracture
Infections and Inflammatory
-Rheumatoid Arthritis
-Septic arthritis
-Otitis media
-Mastoditis
-Parotitis
-Osteoarthritis
Systemic disease
-Small pox
-Ankylosing spondylitis
-Syphilis
-Typhoid fever
-Scarlet fever
Others
-Malignancies
-Post radiology
-Post surgery
-Prolonged trismus

7. PATHOPHYSIOLOGY
TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis

8. CLINICAL FEATURES
•Obvious facial deformity
•Deviation of chin towards affected side
•Inability to open the jaws, absent condylar movements
on affected side
•In unilateral ankylosis, the lower jaws shifts
towards the affected side on opening of the mouth
•Flatness or fullness on affected side
•Cross bite on ipsilateral side
•Class II malocclusion on affected side

10. RADIOGRAPHIC FEATURES
 Fusion of joint
 Loss of joint space
 Prominent antigonial notch
 Coronoid hyperplasia

12. SEQUELAE OF TMJ ANKYLOSIS
•Facial growth distortion
•Nutritional impairment
•Respiratory disorders
•Malocclusion
•Poor oral hygiene
•Multiple carious and impacted teeth

13. MANAGEMENT
 Non surgical management
 Surgical treatment

14. SURGICAL MANAGEMENT
Aims and Objectives of surgery
To release ankylosed mass and creation of a gap
Creation of functional joint (improve patient’s oral hygiene,
nutrition and good speech)
To reconstruct the joint and restore the vertical height of the ramus
To prevent recurrence
To restore normal facial growth pattern

15. Procedures
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty

16. CONDYLECTOMY
•Fibrous ankylosis
•Pre-auricular incision is made
•Cut at the level of the condylar neck
•The head (condyle) should be separated
from the superior attachment carefully
•The wound is then sutured in layers
•The usual complication of this procedure is an ipsilateral deviation
to the affected side. And anterior open bite if the procedure was
bilaterally.

17. GAP ARTHROPLASTY
 Extensive bony ankylosis.
The section here consists of two
horizontal osteotomy cuts
 removal of bony wedges for creation of a
gap between the roof of the glenoid fossa
and the ramus of the mandible.
This gap permits mobility
The minimum gap should be 1cm to
avoid re-ankylosis

18. INTERPOSITIONAL ARTHROPLASTY
This is actually an improvement/modification on gap arthroplasty
Currently the surgical protocol of choice
Materials are used to interpose between the ramus of the mandible
and base of the skull to avoid re-ankylosis
The procedure involves the creation of gap, but in addition, a barrier
is inserted between the two surfaces to avoid reoccurrence and to
maintain the vertical height of the ramus

20. MATERIALS USED IN INTERPOSITIONAL
ARTHROPLASTY
Autogenous Heterogenous Alloplastic
I. Temporalis muscles
II. Temporalis fascia
III. Fascia lata
IV. Cartiligenous grafts
Costochondral
Metatartsal
Sternoclavicular
Auricular graft
V. Dermis
I. chromatised
submucosa of pig’s
bladder
II. lyophilized bovine
cartilage
Metallic: tantalum foil
and plate, stainless steel,
Titanium, Gold.
Nonmetallic: silastic,
Teflon, acrylic, nylon,
ceramic

21. Autografts, such as skin, temporalis muscle, or
fascia lata, are presently considered the material
of choice for interposition.
Advantages of these flaps in TMJ reconstruction include
close proximity to the TMJ without involving an additional surgical
site.

22. Complications of the surgery
Intra-Operative
Haemorrhage (damage of any superficial temporal vessels, transverse
facial artery, etc)
Damage to the external auditory meatus
Damage to the Zygomatic and temp. branch of facial nerve
Damage to the Auriculotemporal nerve
Damage to the Parotid gland
Damage to the teeth
Post Operative
infection
open bite

23. RECURRENCE OF TMJ ANKYLOSIS
•Inadequate gap created between the fragments
•Fracture of the costochondral graft
•Inadequate coverage of the glenoid fossa surface
•Inadequate post-op physiotherapy
•Higher osteogenic potential and periostal osteogenic power may be
responsible for high rate of recurrence in children