overview of TMJ ankylosis,
craniomandibular ankylosis, sequelae of temporomandibular joint disorders, functional derangement, aims of surgery and strategies of intervention with possible complications that may follow
2. ∗ CMJ anatomy overview
∗ Definition of CMJ ankylosis
∗ Etiology
∗ Classification
∗ Clinical presentation
∗ Management strategies
∗ Complications
∗ Current understanding…presentation of Prof Guthua
Presentation Outline
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3. ∗ Bilateral diarthrosis – right & left function together
∗ Articular surface covered by fibrocartilage instead of
hyaline cartilage
∗ Only joint in human body to have a rigid end-point of
closure that of the teeth making occlusal contact.
∗ CMJ is last diarthrodial joints joint to start develop,
7th week in-utero.
∗ Structured like 2 joints. Has 2 synovial cavities
∗ Capable of the largest proportion of translation and
rotation.
Peculiarity of CMJ
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4. Anatomy of CMJ; Components
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5. ∗ The articular surface lined by a layer of fibrocartilage.
Absorbs masticatory forces better than hyaline cartilage
Superior reparative process.
∗ Articular disc attached to the fibrous capsule at the
peripheries
∗ The articular disc maximizes the congruency within
the CMJ to reduce contact pressure
Cont…
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6. ∗ Fibrous capsule
The capsule is relatively firm medially and laterally ,
providing stability to the joint during lateral movements
during mastication.
capsule is relatively lax anteriorly and posteriorly,
allowing the condyle and disc to translate forward when
the mouth is opened.
∗ Lateral ligament(temporomandibular ligament)
Primary lig. Has oblique and horizontal fibres)
∗ Accessory ligs..spheno and stylomandibular ligs.
Located medial to the joint capsule. Suspend the
mandible to the cranium
Cont…
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8. ∗ Stability factors
Static..
Dynamic
∗ Movements …produced by attachments of muscles
of mastication
Protrusion and retraction
Elevation and depression
Lateral excursions
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Athrokinematics of CMJ
9. ∗ Rotational movement
Mandibular condyle rolls relative to the inferior surface
of the disc.
Happens in the lower joint compartment
∗ Translational movement
Mandibular condyle and disc slide essentially together.
The disc usually moves in the direction of the translating
condyle.
The upper joint compartment
Athrokinematics of CMJ
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10. ∗ Early phase, constituting the first 35% to 50% of the
range of motion
involves primarily rotation of the mandible relative to
the cranium
∗ Late phase - 50% to 65% of the total range of motion.
Is marked by a gradual transition from primary rotation
to primary translation
Athrokinematics of CMJ
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19. ∗ Facial growth distortion… Aesthetics
∗ Nutritional impairment
∗ Respiratory disorders
∗ Malocclusion
∗ Poor oral hygiene
∗ Multiple carious and impacted teeth
Sequelae of CMJ Ankylosis
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20. ∗ 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
Aims of Management
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21. Principles of Management
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∗ Early surgical intervention
∗ Elaborate resection
∗ Early mobilization
∗ Aggressive physiotherapy for at least 6 months post
operatively
22. ∗ Ipsilateral coronoidectomy and contralateral
coronoidectomy for longstanding ipsilateral CMJ
ankylosis
∗ Psychological rehabilitation
Principles of Management
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23. ∗ Non-surgical management vs Surgical treatment
∗ Surgical Management
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty
4. Total joint reconstruction
Management Strategies
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24. • Fibrous ankyloses
• 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.
Condylectomy
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25. ∗ Extensive bony ankylosis.
∗ 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
∗ Minimum gap should be 1cm to avoid re-ankylosis
Gap Arthroplastry
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26. ∗ Improvement/modification on gap arthroplasty
∗ Currently the surgical protocol of choice
∗ Involves the creation of gap, with a barrier is inserted
between the two surfaces to avoid re-occurrence and
to maintain the vertical height of the ramus
Interpositional Arthroplasty
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28. ∗ Re-ankylosis
∗ Resorption
∗ Overgrowth
∗ Fracture
∗ Pain
Post-op. Complications
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29. ∗ Inadequate gap btw fragments
∗ Inadequate coverage of glenoid fossa
∗ Inadequate post-op physiotherapy
∗ Fracture of costochondral graft
∗ High osteogenic potential and periosteal osteogenic
power responsible for high recurrence in children
Recurrence of CMJ Ankylosis
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30. ∗ The results of the meta-analysis showed that IPG
results in a significant improvement in MIO and lower
recurrence rate when compared to GA.
∗ IPG showed a greater improvement in MIO and
comparable recurrence rate when compared to CCG
reconstruction.
∗ GA and CCG reconstruction had a comparable
recurrence rate.
∗ CCJ provides greater MIO when compared to AJR,
whereas AJR was superior to CCJ in reducing pain.
Al-moraissi ea et al. A systematic review and meta-analysis of the clinical outcomes for various surgical modalities in the
management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg. 2015 apr;44(4):470-82.
Studies
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31. ∗ 17 studies with 740 participants were included in the
final analysis. The IPG therapy showed a significantly
greater MIO when compared to GA.
∗ The analysis showed that IPG was more effective and
displayed a lower recurrence rate, followed by AR and
GA, in treating CMJ ankylosis.
∗ Analysis provides strong evidence supporting IPG as a
first-line therapy for CMJ ankylosis.
Liu x et al. (2015) effectiveness of different surgical modalities in the management of temporomandibular joint
ankylosis: a meta-analysis. Article · Literature Review in International Journal of Clinical and Experimental
Medicine 2015 Nov. 15;8(11):19831-9.
Studies
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32. ∗ Retrospective study evaluated the cause of CMJ
ankylosis and the 36-month postoperative results of
gap arthroplasty in 50 patients (62 joints).
∗ Result. Trauma to the CMJ was documented as a
major etiologic factor in 86% of cases.
∗ The recurrence rate was 2%.
∗ The long-term functional results of gap arthroplasty
are satisfactory and comparable to other modalities
∗ Postoperative exercises play a crucial role in lasting
success.
Roychoudhury et al. Functional restoration by gap arthroplasty in temporomandibular joint ankyloses.Oral surg oral med
oral pathol oral radiol endod 1999;87:166-9
Studies
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33. 1. Mérida-velasco JR et al. Development of the human temporomandibular joint. The anatomical record.1999
may 1;255(1):20-33.
2. Akama, M.K., Guthua, S., Chindia, M.L., Kahuho, S.K. Management of bilateral temporomandibular joint
ankylosis in children: case report. East Afr Med J. 2009;86:45–48.
3. Illustrated dental embryology, histology, and anatomy, bath-balogh and fehrenbach, 2011, page 266.
4. Malik, N.A. Textbook of oral and maxillofacial surgery. Jaypee Brothers Medical Publishers Ltd, New
Delhi; 2002:207–218.
5. Roychoudhury et al. Functional restoration by gap arthroplasty in temporomandibular joint ankyloses.Oral
surg oral med oral pathol oral radiol endod 1999;87:166-9
6. Xiang g et al. (2014) A retrospective study of temporomandibular joint ankylosis secondary to surgical
treatment of mandibular condylar fractures. Br J oral maxillofac surg 52: 270-274.
7. Madhumati.S. et al. CMJ ankylosis: management with reconstruction and interpositional arthroplasty. Int J
Oral Maxillofac Surg. 2015 oct-dec;24(4):374-9.
8. Khadka, A., Hu, J. Autogenous grafts for condylar reconstruction in treatment of CMJ ankylosis: current
concepts and considerations for the future. Int J Oral Maxillofac Surg. 2012;41:94–102.
9. Al-moraissi ea et al. A systematic review and meta-analysis of the clinical outcomes for various surgical
modalities in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg. 2015
apr;44(4):470-82.
10. Liu x et al. (2015) Effectiveness of different surgical modalities in the management of temporomandibular
joint ankylosis: a meta-analysis. Article · Literature Review in International Journal of Clinical and
Experimental Medicine 2015 Nov. 15;8(11):19831-9.
11. Https://clinicalgate.Com
References and Bibliography
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Working/rotating vs balancing side/orbiting side
Diathrosis..articulation that permits free movt..
This work establishes three phases in CMJ development: 1) the blastematic stage (weeks 7-8 of development); 2) the cavitation stage (weeks 9-11 of development); and 3) the maturation stage (after week 12 of development). This study identifies the critical period of CMJ morphogenesis as occurring between weeks 7 and 11 of development.
This is the last growth center of bone in the body and is multidirectional in its growth capacity, unlike a typical long bone. This area of cartilage within the bone grows in length by appositional growth as the individual grows to maturity.
Develops from 2 different blastemal condylar and temporal
Components of CMJ .Mandibular condyle, articular surface of the temporal bone, capsule, articular disc, ligamanet and muscles of mastication.
Articular surfaces lined by fibrocartilage
Upper compartment larger than the lower compartment …hinging movt lower and gliding upper compartment
Dissipation of the pressure
Articular disc…avascular in the centre and no sensory innervation
Triangular lig. Base at the zygomatic process of temporal bone and articular tubercle base at the lateral side of the neck of the mandible
a forward and downward sliding motion- translation
Translation..changes the axis of rotation
The resting position of the temporomandibular joint is not with the teeth biting together. Instead, the muscular balance and proprioceptive feedback allow a physiologic rest for the mandible, an interocclusal clearance or freeway space, which is 2 to 4 mm between the teeth.[2]
Decline..better understanding of management of condylar fractures..use of antibiotics..decline of otitis media
Pathologies among others ankyloses, dislocation, arthritis
True ankyloses Intra-capsular condition - fusion of the bony surfaces of the joint - the condyle and glenoid fossa.
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
Others malignancies, post surgery, post radiation, iatrogenic
Infections include NOMA;gangrenous stomatitis
Imaging modalities OPG or Lateral Cephalogram, transcranial , Reverse Townes views, CMJ tomograms,transpharyngeal …CT, and 3 D printing models.
MRI for joint derangement…articular disc
Is a serious and disabling condition in children
Aims..look from children vs adult perspective…for children restoring normal growth pattern is important.
Non surgical…physiotherapy
Condyles are not the primary determinants of the mandibular growth
Costochondral graft allows for growth of the ramus …= 1.5cm of costochondral bone rib 5-7 rib. Cosmetic surgery follows after completion of growth..complication…2nd surgery site, overgrowth..donor site complication,,,pneumothorax, pleuritic pain..
MIO= maximal interincisor opening CCG=costochondral graft, GA= gap arthroplasty . Alloplastic joint reconstruction =AJR costochondral joint= (CCJ)
International journal of oral and maxillofacial surgery..