INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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CASE...
GENERAL
INFORMATION

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Patient named Madhavi of
age 7 yrs hailing from
Aravapalem village came
...
History of present illness-

No history of ear infections.

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The patients attenders elicits Hi...
Medical history-

No relevant personal dental and family history

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On her 4th day after birth ...
General examination-

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Patient is poorly built and
malnourished.
Pallor
Vitals – no signifi...
Systemic examinationno relevant abnormality detected.
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Local examinationExtra oral- On InspectionFacial asymmetry detected with soft tissue
fullness on left side.
Chin deviated ...
Extra oral examinationPalpationOn palpation the inspectory finding are
confirmed.

Prominent gonial angle on left side.
S...
Intra oral examinationOn inspection anterior open bite
present.

Class – 2 malocclusion

Midline shift-7mm
Malposition...
Provisional clinical diagnosis-

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Unilateral left TMJ ankylosis.
Investigations –
Radiological-

CT Scan with 3-D reconstruction.
Surgical profile

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O.P.G.
O.P.G

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C.T Scan-

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Comparision of left and right

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Radiological diagnosisUnilateral left bony ankylosis of TMJ.
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Treatment plan-

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Aggressive resection of left condyle and coronoid with
interpositional arth...
DEFINITIONS
True ankylosis

Pseudo-ankylosis
Mechanical interference - joint hypomobility
and the joint is normal.
Fibrous...
CLASSIFICATIONS
KAZANJIAN (1938)

b. False ankylosis

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a. True ankylosis
CLASSIFICATIONS









Fibrous
Fibro-osseous
Osseous
Cartilaginous

Pseudo-ankylosis
False ankylosis.

www.indiand...
Sawhney’s classification (1986):

CLASSIFICATIONS
TYPE-2
Deformed
condylar head
with lost
function,decreased joint space
a...
CLASSIFICATIONS
Based on etiology:
Traumatic
Congenital (Forcep delivery)
Childhood trauma
Adulthood trauma

Can also be
i...
Systemic inflammatory&rheumatological disease.
(10%)
Rheumatoid arthritis (30-70%)



Psoriatic arthritis (1-2%)



Anky...
Classification on CT findings-Sashi aggarwal(1989)
 Type

II-joint architecture completely
disrupted
large mass of bone
m...
CLASSIFICATIONS
Modified classification based on CT-scan: El-Hakim, S A

Metwalli (2003)
Class I- includes uni &bil fibrou...
CLASSIFICATIONS
Topazian three-stage classification

I, ankylotic bone limited to the condylar
process;

 stage

II, anky...
ETIOLOGICAL FACTORS
HYPO-MOBILITY


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TRISMUS
Odontogenic
Infection
Trauma
Tumours
Psychologic...
 PSEUDOANKYLOSIS

1.DEPRESSED ZM ARCH #

3.ADHESIONS OF CORONOID PROCESS
4.HYPERTROPHY OF CORONOID PROCESS

5.FIBROSIS OF...
TRUE ANKYLOSIS


TRAUMA(31—98%)
1.Intracapsular # in child

3.Intracapsular fibrosis
4.Obstetric trauma(Foreceps delivery...


INFLAMMATION(10%)
1.Rheumatoid arthritis

2.Still’s disease(juvenile idiopathic arthritis)
4.Psoriatic arthritis


IAT...
ETIOLOGIES
Organisms may reach the joint by instrumentation
Lacerated wound.

2.

Through bloodstream

3.

Direct extensio...
TOPAZIAN LISTS THREE MECHANISMS

1.

Primary Otitis media causing secondary joint

2.

Suppurative arthritis of TMJ involv...
Infection from mastoiditis in 3 ways
1.

2.

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3.

Direct extension
Thrombophlebitis
Hematogeno...
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PATHOGENESIS
ETIO-PATHOGENESIS
Microtrauma
Local Infections

Systemic Infections

Hemarthrosis
Drop in O2 Tension
& PH

Promotes
Osteos...
DIAGNOSIS
History, Clinical, Radiographic examination.
Norman Rowe
2. Inability to open mouth or marked limitation.
3. Sli...
5. Asymmetry of the face

6. Flattening of face
7. Shift of symphysis

9. Shortness of vertical and horizontal ramus of th...
CLINICAL MANIFESTATIONS
Vary according to
Severity of onset

2.

Time of onset

3.

Duration

Early-below 15 years, severe...
UNILATERAL ANKYLOSIS
 Obvious

deformity

 Chin

to affected side

receded with hypoplastic

mandible on affected side
...
BILATERAL ANKYLOSIS
 MIO

decreases

- micro

but symmetrical
 Bird

face deformity

 Neck

chin angle - absent

 Mult...
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RADIOLOGY
RADIOGRAPHS
OPG



Lateral Tomograms



PA Mandible



Trans cranial TMJ



Contrast enhanced CT scan.



MRI



3-D...
PANORAMIC VIEWS
Joint deformity
Loss of the joint space
Abnormal bone formation in and around the joint,

These details ar...
ANESTHETIC CONSIDERATIONS


Limited protrusion, diminished lateral excursion, as well as
trismus.
Failure to properly man...
TECHNIQUES

www.indiandentalacademy.com

If the mouth opens less than 25 mm,
 Transoral fibreoptic bronchoscopy-assisted ...


Incidence of laryngospasm - 8.6 : 1000 in adults and
27.6 : 1000 in children



Topical lidocaine, succinylcholine, an...
ANKYLOSIS IN CHILDREN
REASONS:
1. Articulating surfaces highly vascular
3. Vascular articulating disc
4. Thick and stout c...
SURGICAL TREATMENT IN CHILDREN
Two objectives
1. To improve mandibular function

1. Type 1&2 high condylar shave. 3-4mm of...
SURGICAL ACCESS TO TMJ


Potential problems
Facial nerve
Terminal branches of ECA


Serious morbidity from facial nerve ...
APPROACHES
• Preauricular
• Postauricular

• Rhytidectomal
• Submandibular
• Intraoral

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• End...
OBJECTIVES

GOALS

Maximize exposure

prevent disease progression



Facial nerve

restore mandibular form



Major vess...
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PREPARATION FOR SURGERY…..
PREAURICULAR APPROACH (BLAIR)
MODIFICATION OF THE BLAIR CURVILINEAR OR INVERTED- L
INCISION

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ENDAURAL APPROACH

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ADVANTAGES
Excellent access to the lateral and posterior
aspects of the joint
 Esthetically acceptable
 Scar hidden


w...
AL-KAYAT & BRAMLEY (1979)
MODIFIED PRE-AURICULAR APPROACH

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

Following advantages,








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

Minimal bleeding and less sensory loss.
Facial plan...
Others


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POSTAURICULAR APPROACH
(ALEXANDER & JAMES-1975)

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ADVANTAGES
Excellent exposure of the entire joint
 Ability to camouflage the scar in patients –
keloids.


should not be...
SUBMANDIBULAR APPROACH
(RISDON-1934)

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RHYTIDECTOMY
Face-Lift approach
 Variant of the retromandibular approach.
 Difference - placement of the incision.
 Pro...
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TREATMENT OPTIONS
1. Gap arthroplasty

3. Joint reconstruction

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2. Interpositional arthroplas...
TREATMENT DECISION MAKING

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GAP ARTHROPLASTY

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ADVANTAGES
 Simplicity
 Short

operating time

 Pseudo-articulation
 Short

ramus height
 Failure to remove all bony ...
INTERPOSITIONAL ARTHROPLASTY
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TEMPORALIS FASCIA FLAP

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ADVANTAGES
Simplicity
 Short operating time


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DISADVANTAGES
 Donor site morbidity if auto…...
KABAN’S PROTOCOL (1990)
Aggressive resection

2.

Ipsilateral coronoidectomy

3.

Contralateral cronoidectomy (if necessar...
SALIN’S PROTOCOLThe ankylotic mass itself is not resected
 Bone is not removed to create a gap
 Functional pseudoarthros...
OTHER TECHNIQUES PROPOSED





www.indiandentalacademy.com



Nitzan et al.- in type 3 ankylosis involving TMJ
preserv...
CONTD..,


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Balaji evaluated the long termoutcome of
temporalis flap with sub-condylar anchor...
RECONSTRUCTION

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AUTOGENOUS AND ALLOPLASTIC
GOALS FOR TMJ RECONSTRUCTION
of joint and muscle pain.

 Restoration

of normal joint function

 Restoration

normal pos...
AUTOGENOUS TMJ REPLACEMENT


1909 – Bardenheur - replaced condyle - 4th metatarsal



1920 - Gillies used costochondral ...


Purpose of using costochondral grafts for reconstruction
of TMJ ankylosis is twofold:

ankylosis,
2) To restore the joi...
ADVANTAGES


Biologic acceptability and remodeling by
oppositional growth, especially in children
www.indiandentalacademy...
COMPLICATIONS
Donor site morbidity,
such as
 Pneumothorax & pleuritic pain
 Potential overgrowth of the graft
 Suboptim...
intra-articular adhesions,

prevent soft tissue contraction
stretch maturing fibrous tissue,
 redevelop normal
muscle ...
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ALLOPLASTIC JOINT REPLACEMENTS
HISTORY
John Murray treated ankylosis - wood block

 1890–

Gluck - ivory prosthesis

 1933

– Risdon – gold foil

 194...
INDICATIONS


Ankylosed, degenerated or resorbed joints with severe



Failed autogenous bone grafts



Destruction of ...
RELATIVE CONTRAINDICATIONS
Insufficient patient age



Lack of understanding of the patient



Uncontrolled systemic dis...
ADVANTAGES
Physical therapy can begin immediately
 No need for second donor site
 Reduced surgical time
 Alloplasts – m...
DISADVANTAGES
Cost of prosthesis



Material wear and failure



Long term stability



Inability to follow patients gr...
ALLOPLASTIC CONDYLAR
PROSTHESIS
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KENT-VITEK TOTAL JOINT PROSTHESIS
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CHRISTENSEN SYSTEM
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Metal to metal

Type1 & 2
COMPLICATIONS
Foreign-body reaction to some materials
 Erosion of metal condylar prosthesis into the
glenoid fossa
 Subo...
FAILURES

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DIAGNOSIS OF FAILED ALLOPLASTIC IMPLANTS
 Swelling

with or without visual confirmation and
ed tightness in and around jo...
ON THE WORK OF GHELMAN - RADIOGRAPH OF ANY
ALLOPLASTIC TMJ REPLACEMENT:

1. The position of the components,

3. The presen...
COMPLICATIONS
1.

Bleeding
1.
2.
3.

3.
4.
5.
6.
7.

Facial Neuropraxia
Wound Infection
Venous thrombosis
Frey’s syndrome
...
COMPLICATIONS

Prevention of re-ankylosis



www.indiandentalacademy.com

8. Reankylosis

10-15% of cases

Within 6 mo...
POST-OP REHABILITATIONDISTRACTION OSTEOGENESIS- of body of
mandible- one stage vs two stage2011 American
Association of Or...
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CONCLUSION
REFERENCES
*A TEXTBOOK & COLOUR ATLAS OF TMJ DISEASES,
DISORDER, SURGERY - J. E. DeBURGH NORMAN
*MAXILLOFACIAL TRAUMA – RO...
REFERENCES
*A Protocol for Management Of TMJ Ankylosis
Leonard B Kaban, David H Perrott, Keith Fisher JOMS; 48; 1990:
1145...
REFERENCES
*The Effect Of Intra-Articular Bone Fragments In Genesis of
TMJ Ankylosis - H Miyomoto, K Kurith, N Ogi,
*Devel...
For more details please visit
www.indiandentalacademy.com

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Temporomandibular joint /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Temporomandibular joint /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com CASE PRESENTATION
  2. 2. GENERAL INFORMATION www.indiandentalacademy.com Patient named Madhavi of age 7 yrs hailing from Aravapalem village came to the department with the chief complaint of inability to open the mouth .
  3. 3. History of present illness- No history of ear infections. www.indiandentalacademy.com The patients attenders elicits History of delivery in a public bus where the child had a fall to the floor of bus, the point of impact is not known. There was a partial mouth opening at birth which gradually decreased to the present condition.
  4. 4. Medical history- No relevant personal dental and family history www.indiandentalacademy.com On her 4th day after birth Underwent treatment to right eye after she had trauma due to accidental hit of her grandmother’s nail while bathing, during the treatment period there was infection and resulted in loss of vision within 7 days.
  5. 5. General examination- www.indiandentalacademy.com Patient is poorly built and malnourished. Pallor Vitals – no significant findings detected BP-120/80 mm of Hg Temperature – afebrile RR-20 times/min PR-84 times/min
  6. 6. Systemic examinationno relevant abnormality detected. www.indiandentalacademy.com
  7. 7. Local examinationExtra oral- On InspectionFacial asymmetry detected with soft tissue fullness on left side. Chin deviated to left-1cm Mouth opening restricted-1mm No lateral and antero-posterior extrusive movements of lower jaw. Chin receeded with hypoplastic mandible. Condylar movements severly restricted. Thyro- mental angle reduced. Shortening of ramus is observed on the left side. www.indiandentalacademy.com Lips incompetent
  8. 8. Extra oral examinationPalpationOn palpation the inspectory finding are confirmed. Prominent gonial angle on left side. Steep mandibular angle on left. Short body of mandible on the left side. Foreshortening of Ramus on left side. Condyle movement is severely restricted. On clenching masseter muscle is tensed www.indiandentalacademy.com Lower border of mandible is concave on left side with Accentuated antegonial notch on both sides with more severity on left.
  9. 9. Intra oral examinationOn inspection anterior open bite present. Class – 2 malocclusion Midline shift-7mm Malpositioning of teeth. Tongue thrust is positive. Right side scissor bite and left side cross bite. Poor oral hygiene. Mild difficulty in deglutition. www.indiandentalacademy.com Overjet-9mm
  10. 10. Provisional clinical diagnosis- www.indiandentalacademy.com Unilateral left TMJ ankylosis.
  11. 11. Investigations – Radiological- CT Scan with 3-D reconstruction. Surgical profile www.indiandentalacademy.com O.P.G.
  12. 12. O.P.G www.indiandentalacademy.com
  13. 13. C.T Scan- www.indiandentalacademy.com
  14. 14. Comparision of left and right www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com
  17. 17. www.indiandentalacademy.com
  18. 18. Radiological diagnosisUnilateral left bony ankylosis of TMJ. www.indiandentalacademy.com
  19. 19. Treatment plan- www.indiandentalacademy.com Aggressive resection of left condyle and coronoid with interpositional arthroplasty by temporalis muscle or costochondral graft. Followed by aggressive physiotherapy and muscle excercises .
  20. 20. DEFINITIONS True ankylosis Pseudo-ankylosis Mechanical interference - joint hypomobility and the joint is normal. Fibrous ankylosis, coronoid hyperplasia or fusion of coronoid process with the tuberosity of maxilla or zygoma are examples of pseudoankylosis www.indiandentalacademy.com Intra-capsular condition - fusion of the bony surfaces of the joint - the condyle and glenoid fossa.
  21. 21. CLASSIFICATIONS KAZANJIAN (1938) b. False ankylosis www.indiandentalacademy.com a. True ankylosis
  22. 22. CLASSIFICATIONS       Fibrous Fibro-osseous Osseous Cartilaginous Pseudo-ankylosis False ankylosis. www.indiandentalacademy.com ROWE’S MODIFICATION (1986)  True ankylosis:
  23. 23. Sawhney’s classification (1986): CLASSIFICATIONS TYPE-2 Deformed condylar head with lost function,decreased joint space and dense fibrous adhesion .TYPE-3 Bony block from asc ramus to zygomatic arch, condyle deformed . Ant or post bony fusion of misshaped condyle with articular surface,lateral lipping . www.indiandentalacademy.com TYPE -1 TYPE-4 Totally deformed anatomy, bony mass,with complete fusion
  24. 24. CLASSIFICATIONS Based on etiology: Traumatic Congenital (Forcep delivery) Childhood trauma Adulthood trauma Can also be i. Osseous ii. Fibro-osseous iii. Fibrous iv. Cartilaginous or osteocartilaginous www.indiandentalacademy.com   
  25. 25. Systemic inflammatory&rheumatological disease. (10%) Rheumatoid arthritis (30-70%)  Psoriatic arthritis (1-2%)  Ankylosis spondylitis (1-50%) Others  Scleroderma  TMJ surgeries  Irradiation  Idiopathic (50%)  Osteochondromas www.indiandentalacademy.com •
  26. 26. Classification on CT findings-Sashi aggarwal(1989)  Type II-joint architecture completely disrupted large mass of bone midline shifted to the affected side 3.5 cm in maximum thickness www.indiandentalacademy.com  Type I-condyle could be identified mild to moderate bone formation lateral part of articular fossa 2.5 cm in max thickness
  27. 27. CLASSIFICATIONS Modified classification based on CT-scan: El-Hakim, S A Metwalli (2003) Class I- includes uni &bil fibrous ankylosis  Class II-uni or bil bony fusion  Class III- distance b/n maxillary artery & the medial pole of the mandible is less on the ankylosed side  Class IV-ankylosed mass appeared fused to the base of skull www.indiandentalacademy.com 
  28. 28. CLASSIFICATIONS Topazian three-stage classification 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. www.indiandentalacademy.com  stage
  29. 29. ETIOLOGICAL FACTORS HYPO-MOBILITY  www.indiandentalacademy.com TRISMUS Odontogenic Infection Trauma Tumours Psychologic Pharmacologic Neurologic
  30. 30.  PSEUDOANKYLOSIS 1.DEPRESSED ZM ARCH # 3.ADHESIONS OF CORONOID PROCESS 4.HYPERTROPHY OF CORONOID PROCESS 5.FIBROSIS OF TEMPORALIS MUSCLE 6.MYOSITIS OSSIFICANS 7.SCAR CONTRACTURE 8.TUMOUR OF CONDYLE OR CORONOID www.indiandentalacademy.com 2.FRACTURE DISLOCATION OF CONDYLE
  31. 31. TRUE ANKYLOSIS  TRAUMA(31—98%) 1.Intracapsular # in child 3.Intracapsular fibrosis 4.Obstetric trauma(Foreceps delivery)  INFECTION(10—30%) 1.Otitis media 2.Suppurative arthritis www.indiandentalacademy.com 2.Medial displaced condylar # adults
  32. 32.  INFLAMMATION(10%) 1.Rheumatoid arthritis 2.Still’s disease(juvenile idiopathic arthritis) 4.Psoriatic arthritis  IATROGENIC Postoperative complication of 1.TMJ surgery 2.Orthognathic surgery www.indiandentalacademy.com 3.Ankylosing spondylitis
  33. 33. ETIOLOGIES Organisms may reach the joint by instrumentation Lacerated wound. 2. Through bloodstream 3. Direct extension from infection of neighboring structures. 4. www.indiandentalacademy.com 1. Blunt trauma. Staphylococci, streptococci and occasionally gonococci.
  34. 34. TOPAZIAN LISTS THREE MECHANISMS 1. Primary Otitis media causing secondary joint 2. Suppurative arthritis of TMJ involving the middle ear secondarily 3. Suppurative arthritis of the joint draining into the cartilaginous canal. www.indiandentalacademy.com involvement.
  35. 35. Infection from mastoiditis in 3 ways 1. 2. www.indiandentalacademy.com 3. Direct extension Thrombophlebitis Hematogenous dissemination Dried skull > 10 years of age - tiny opening or perforation in the central part of the tympanic plate - incomplete ossification. Infection can spread through 1. Opened sutures 2. Incomplete ossification 3. Delayed ossification
  36. 36. www.indiandentalacademy.com PATHOGENESIS
  37. 37. ETIO-PATHOGENESIS Microtrauma Local Infections Systemic Infections Hemarthrosis Drop in O2 Tension & PH Promotes Osteosynthesis Ankylotic Mass www.indiandentalacademy.com Trauma
  38. 38. DIAGNOSIS History, Clinical, Radiographic examination. Norman Rowe 2. Inability to open mouth or marked limitation. 3. Slight motion of the condyle of the non-involved side. 4. Slight motion from springing of the fibro-osseous tissue on the involved side; in the bilateral case, movement may be impossible. www.indiandentalacademy.com 1. H/O injury to, or infection of the jaws.
  39. 39. 5. Asymmetry of the face 6. Flattening of face 7. Shift of symphysis 9. Shortness of vertical and horizontal ramus of the mandible. 10. Deep antegonial notch on the involved side. 11. Decreased or almost absent joint space www.indiandentalacademy.com 8. Normal occlusion of the teeth on uninvolved side
  40. 40. CLINICAL MANIFESTATIONS Vary according to Severity of onset 2. Time of onset 3. Duration Early-below 15 years, severe facial deformity and loss of function Late– after 15 yrs.. Facial deformity nil, function loss www.indiandentalacademy.com 1.
  41. 41. UNILATERAL ANKYLOSIS  Obvious deformity  Chin to affected side receded with hypoplastic mandible on affected side  Lower border - concavity  Cross bite  Class II  Condylar movements absent www.indiandentalacademy.com  Deviation
  42. 42. BILATERAL ANKYLOSIS  MIO decreases - micro but symmetrical  Bird face deformity  Neck chin angle - absent  Multiple  Less carious tooth than 5 mm  Upper incisors often protrusive www.indiandentalacademy.com  Mandible
  43. 43. www.indiandentalacademy.com RADIOLOGY
  44. 44. RADIOGRAPHS OPG  Lateral Tomograms  PA Mandible  Trans cranial TMJ  Contrast enhanced CT scan.  MRI  3-D reconstruction www.indiandentalacademy.com 
  45. 45. PANORAMIC VIEWS Joint deformity Loss of the joint space Abnormal bone formation in and around the joint, These details are clearly apparent - CORONAL CT - illustrate whether the ankylotic mass is fibrous or bony. POST-CONTRAST CT demonstrate the relation to surrounding vital structures, especially the maxillary artery. These findings ASSIST in Better surgical planning and therefore reduced operating time and surgical complications. www.indiandentalacademy.com Do not reveal the nature and the extent of the pathology, in particular the medial and lateral extension of the ankylosed bony mass, and its relation to surrounding vital structures.
  46. 46. ANESTHETIC CONSIDERATIONS  Limited protrusion, diminished lateral excursion, as well as trismus. Failure to properly manage the airway - life threatening  Conventional tracheal intubation cannot be performed if the MIO < 25mm www.indiandentalacademy.com 
  47. 47. TECHNIQUES www.indiandentalacademy.com If the mouth opens less than 25 mm,  Transoral fibreoptic bronchoscopy-assisted intubation,  Transnasal fibreoptic bronchoscopy-assisted intubation,  Tracheostomy, or  Blind nasal intubation should be performed under sedation or using general inhalation anaesthesia with the patient breathing spontaneously
  48. 48.  Incidence of laryngospasm - 8.6 : 1000 in adults and 27.6 : 1000 in children  Topical lidocaine, succinylcholine, and positive pressure  Bilateral superior laryngeal nerve block -severe repeated postoperative laryngospasm www.indiandentalacademy.com ventilation - standard management of laryngospasm
  49. 49. ANKYLOSIS IN CHILDREN REASONS: 1. Articulating surfaces highly vascular 3. Vascular articulating disc 4. Thick and stout condylar neck 5. Hemoarthrosis and CO2 tension 6. Greater osteoblastic activity www.indiandentalacademy.com 2. Flat and broad glenoid fossa
  50. 50. SURGICAL TREATMENT IN CHILDREN Two objectives 1. To improve mandibular function 1. Type 1&2 high condylar shave. 3-4mm of gap. Disc to be mobilized 2. Destroyed condyle to be replaced by grafts www.indiandentalacademy.com 2. Normal growth and development
  51. 51. SURGICAL ACCESS TO TMJ  Potential problems Facial nerve Terminal branches of ECA  Serious morbidity from facial nerve overshadows the mechanical improvements in joint function www.indiandentalacademy.com Access to temporomandibular joint - important for surgical success.
  52. 52. APPROACHES • Preauricular • Postauricular • Rhytidectomal • Submandibular • Intraoral www.indiandentalacademy.com • Endaural
  53. 53. OBJECTIVES GOALS Maximize exposure prevent disease progression  Facial nerve restore mandibular form  Major vessels function  Parotid gland diminish patient suffering  Maximize use of skin creases disability www.indiandentalacademy.com o
  54. 54. www.indiandentalacademy.com PREPARATION FOR SURGERY…..
  55. 55. PREAURICULAR APPROACH (BLAIR) MODIFICATION OF THE BLAIR CURVILINEAR OR INVERTED- L INCISION www.indiandentalacademy.com
  56. 56. ENDAURAL APPROACH www.indiandentalacademy.com
  57. 57. ADVANTAGES Excellent access to the lateral and posterior aspects of the joint  Esthetically acceptable  Scar hidden  www.indiandentalacademy.com Disadvantage  potential for perichondritis
  58. 58. AL-KAYAT & BRAMLEY (1979) MODIFIED PRE-AURICULAR APPROACH www.indiandentalacademy.com
  59. 59.  Following advantages,       www.indiandentalacademy.com  Minimal bleeding and less sensory loss. Facial planes arc easily identified. Excellent visibility. Potential complications of muscle herniation and fibrosis are avoided. Remarkably little post-operative discomfort or swelling. Good cosmetic result is achieved except in the very bald. Technique is easily teachable and speedily executed.
  60. 60. Others  www.indiandentalacademy.com
  61. 61. POSTAURICULAR APPROACH (ALEXANDER & JAMES-1975) www.indiandentalacademy.com
  62. 62. ADVANTAGES Excellent exposure of the entire joint  Ability to camouflage the scar in patients – keloids.  should not be used – joint infection chronic otitis externa www.indiandentalacademy.com Disadvantage  Auricular stenosis
  63. 63. SUBMANDIBULAR APPROACH (RISDON-1934) www.indiandentalacademy.com
  64. 64. RHYTIDECTOMY Face-Lift approach  Variant of the retromandibular approach.  Difference - placement of the incision.  Provide greater exposure to the superior joint cavity  However, it requires additional time for closure.  www.indiandentalacademy.com
  65. 65. www.indiandentalacademy.com
  66. 66. TREATMENT OPTIONS 1. Gap arthroplasty 3. Joint reconstruction www.indiandentalacademy.com 2. Interpositional arthroplasty
  67. 67. TREATMENT DECISION MAKING www.indiandentalacademy.com
  68. 68. GAP ARTHROPLASTY www.indiandentalacademy.com
  69. 69. ADVANTAGES  Simplicity  Short operating time  Pseudo-articulation  Short ramus height  Failure to remove all bony disease  Development of open bite {bilat cases}  Suboptimal range of motion  Recurrent ankylosis (60%) www.indiandentalacademy.com DISADVANTAGEs
  70. 70. INTERPOSITIONAL ARTHROPLASTY www.indiandentalacademy.com
  71. 71. TEMPORALIS FASCIA FLAP www.indiandentalacademy.com
  72. 72. www.indiandentalacademy.com
  73. 73. ADVANTAGES Simplicity  Short operating time  www.indiandentalacademy.com DISADVANTAGES  Donor site morbidity if auto….  Risk of foregin body reaction if allop….  Failure to remove all the bony pathology
  74. 74. KABAN’S PROTOCOL (1990) Aggressive resection 2. Ipsilateral coronoidectomy 3. Contralateral cronoidectomy (if necessary) 4. Lining of TMJ with temporalis fascia or cartilage 5. Reconstruction of ramus using costochondral graft 6. Rigid fixation 7. Early immobilization and aggressive physiotherapy www.indiandentalacademy.com 1.
  75. 75. SALIN’S PROTOCOLThe ankylotic mass itself is not resected  Bone is not removed to create a gap  Functional pseudoarthrosis is created between the normal bone surface.  www.indiandentalacademy.com
  76. 76. OTHER TECHNIQUES PROPOSED   www.indiandentalacademy.com  Nitzan et al.- in type 3 ankylosis involving TMJ preservation of existing articular elements to form a joint after selective elimination of the bony bridge, JOMS-1998:56:1133-8 Chossegross et.al- used full thickness skin graft from groin region as inter-positional material and acquired 92% success with 3years follow-up, IJOMS1999:28:330-4 Gunaseelan R. condylar resection in extensive ankylosis in adults followed by usage of resected segment as autograft. IJOMS-1997:26:405-7 Herbosa and Rotskoff –used composite temporalis pedicle flap as an interpositional graft- 18 months of follow-up showed significant improvement in mandibular range of motion due to compensatory rotational movement.-JOMS-1990:48:1049-1056.
  77. 77. CONTD..,  www.indiandentalacademy.com Balaji evaluated the long termoutcome of temporalis flap with sub-condylar anchorage in management of re-ankylosis.IJOMS-2003:32:480485.
  78. 78. RECONSTRUCTION www.indiandentalacademy.com AUTOGENOUS AND ALLOPLASTIC
  79. 79. GOALS FOR TMJ RECONSTRUCTION of joint and muscle pain.  Restoration of normal joint function  Restoration normal posterior vertical dimensions and length.  Stable skeletal occlusal relationship  Maintenance  Lifetime of facial symmetry maintenance of restored function, comfort and esthetics www.indiandentalacademy.com  Elimination
  80. 80. AUTOGENOUS TMJ REPLACEMENT  1909 – Bardenheur - replaced condyle - 4th metatarsal  1920 - Gillies used costochondral graft Costochondral graft Metatarsal graft Sternoclavicular graft Calvarial bone graft AUTOGENOUS DISK REPLACEMENT Dermis graft Auricular graft Temporalis myofacial flap www.indiandentalacademy.com DONOR SITE ALTERNATIVES-
  81. 81.  Purpose of using costochondral grafts for reconstruction of TMJ ankylosis is twofold: ankylosis, 2) To restore the joint’s form and function. www.indiandentalacademy.com 1) To ensure a wide gap arthroplasty for release of the
  82. 82. ADVANTAGES  Biologic acceptability and remodeling by oppositional growth, especially in children www.indiandentalacademy.com DISVANTAGES  Increased operating time  Additional surgical site
  83. 83. COMPLICATIONS Donor site morbidity, such as  Pneumothorax & pleuritic pain  Potential overgrowth of the graft  Suboptimal postoperative range of motion  www.indiandentalacademy.com
  84. 84. intra-articular adhesions, prevent soft tissue contraction stretch maturing fibrous tissue,  redevelop normal muscle function. www.indiandentalacademy.com Early movement will prevent--
  85. 85. www.indiandentalacademy.com ALLOPLASTIC JOINT REPLACEMENTS
  86. 86. HISTORY John Murray treated ankylosis - wood block  1890– Gluck - ivory prosthesis  1933 – Risdon – gold foil  1947 – Goodsell - titanium foil  Total joint - Kent-Vitek prosthesis  Christensen  – 1964 - lined glenoid fossa —vitallium Chase – 1995 - chromium cobalt head www.indiandentalacademy.com  1840–
  87. 87. INDICATIONS  Ankylosed, degenerated or resorbed joints with severe  Failed autogenous bone grafts  Destruction of autogenous bone due to preexisting foreign body reaction.  Recurrent ankylosis.  Severe polyarticular inflammatory joint disease of TMJs www.indiandentalacademy.com anatomic discrepancies
  88. 88. RELATIVE CONTRAINDICATIONS Insufficient patient age  Lack of understanding of the patient  Uncontrolled systemic disease  Allergic to materials used in devices  Active infection at implantation site. www.indiandentalacademy.com 
  89. 89. 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  www.indiandentalacademy.com
  90. 90. DISADVANTAGES Cost of prosthesis  Material wear and failure  Long term stability  Inability to follow patients growth  Potential for severe giant cell reactions www.indiandentalacademy.com 
  91. 91. ALLOPLASTIC CONDYLAR PROSTHESIS www.indiandentalacademy.com
  92. 92. KENT-VITEK TOTAL JOINT PROSTHESIS www.indiandentalacademy.com
  93. 93. CHRISTENSEN SYSTEM www.indiandentalacademy.com Metal to metal Type1 & 2
  94. 94. COMPLICATIONS Foreign-body reaction to some materials  Erosion of metal condylar prosthesis into the glenoid fossa  Suboptimal postoperative range of motion  Loosening of screws and loss of stability  www.indiandentalacademy.com
  95. 95. FAILURES www.indiandentalacademy.com
  96. 96. DIAGNOSIS OF FAILED ALLOPLASTIC IMPLANTS  Swelling with or without visual confirmation and ed tightness in and around joints ed hearing or fullness in the ears without abnormal otologic findings  ed pain in the joint with function with or without headaches in temple area  ing ability to masticate food  ing range of motion  ing sound in the joint  Posterior open bite www.indiandentalacademy.com 
  97. 97. ON THE WORK OF GHELMAN - RADIOGRAPH OF ANY ALLOPLASTIC TMJ REPLACEMENT: 1. The position of the components, 3. The presence of metal fractures, 4. Areas of ectopic bone formation. 5. Metal fragments in and/or around the joint. www.indiandentalacademy.com 2. The position of the fixation screws. 6. Host bone osteolysis around major components and/or fixation screws. 7. Infection.
  98. 98. COMPLICATIONS 1. Bleeding 1. 2. 3. 3. 4. 5. 6. 7. Facial Neuropraxia Wound Infection Venous thrombosis Frey’s syndrome Otitis externa and Otalgia Facial scarring www.indiandentalacademy.com 2. Edge of temporalis muscle. Maxillary and mandibular vessels. Pterygoid venous plexus
  99. 99. COMPLICATIONS Prevention of re-ankylosis   www.indiandentalacademy.com 8. Reankylosis  10-15% of cases  Within 6 months  Especially in children of 6-8yrs of age Physio therapy The post-operative follow-ups should be weekly for the first 1 month, followed by monthly for the next 5 months. Successive follow-up recalls should be made till 2 years post op to ensure that the patient does not develop a re-ankylosed joint.
  100. 100. POST-OP REHABILITATIONDISTRACTION OSTEOGENESIS- of body of mandible- one stage vs two stage2011 American Association of Oral and Maxillofacial Surgeons  J Oral Maxillofac Surg 69:e565-e572, 2011  www.indiandentalacademy.com
  101. 101. www.indiandentalacademy.com CONCLUSION
  102. 102. REFERENCES *A TEXTBOOK & COLOUR ATLAS OF TMJ DISEASES, DISORDER, SURGERY - J. E. DeBURGH NORMAN *MAXILLOFACIAL TRAUMA – ROBERT H. MATHOG *SURGERY OF THE TMJ – DAVID ALEXANDER KEITH DIAGNOSIS, MANAGEMENT - WELDEN E. BELL *ORAL AND MAXILOFACIAL INFECTIONS – TOPAZIAN *TEXT BOOK OF ORAL MEDICINE – BURKETT. *TEMPOROMANDIBULAR DISORDERS – KAPLAN *MANAGEMENT OF TMJ DISORDERS AND OCLUSION – JEFFREY OKESON *MAXILLOFACIAL SURGERY – PETER WARDBOOTH www.indiandentalacademy.com *TEMPOROMANDIBUALR DISORDERS CLASSIFICATION,
  103. 103. REFERENCES *A Protocol for Management Of TMJ Ankylosis Leonard B Kaban, David H Perrott, Keith Fisher JOMS; 48; 1990: 1145-51 *New Perspectives In The Management Of Cranio-Mandibular *Bone Ankylosis of the TMJ. A CT study Sashi Aggarwal, Sima Mukhopadhyaya, Manorama berry, OOO; 1990; 69: 128-32 *Imaging of TMJ; A New Radiographic Classification. IE El-Hakim, S A Metwalli Dentomaxillofacial Radiology 2002; 31; 19-23. *A Clinical Study on TMJ Ankylosis - Behcet Erol, Rezzzan Tanrikulu, Belgin Gorgun J Craniomaxillafacial Surg; 2006; 34 www.indiandentalacademy.com Ankylosis. P C Salins, IJOMS, 2000; 29; 337-40
  104. 104. REFERENCES *The Effect Of Intra-Articular Bone Fragments In Genesis of TMJ Ankylosis - H Miyomoto, K Kurith, N Ogi, *Development of human TMJ - David A Keith BJOMS 1982; 20; 217-20 *TMJ Ankylosis - Henk Tideman ADJ; 1987; 32(3); 171-77 *TMJ Ankylosis following mastoiditis - Thomas H Faerber, Robert Ennis JOMS, 1990; 866-70 www.indiandentalacademy.com IJOMS 2000; 29; 290-95
  105. 105. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com Thank you

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