TMJ

1. Case prsentation
Bilateral TMJ Ankylosis

2. History taking
เพศ หญิง อายุ 8 ปี
CC: อ้าปากได้น้อยมา 8ปี
PI: ตอนอายุ 1 เดือน พลัดตกจากแม่ พึ่ง
สังเกตว่าลูกอ้าปากได้น้อยตอนฟันน้านม
ซี่แรกขึ้น
3 ปี 5 เดือน  Known case Lt
TMJ ankyloses type III, มีแผนผ่าตัดตอน
อายุ 6 ปี
5 ปี  เริ่มมีปัญหาหายใจ
ลาบากตอนนอน นอนกรนเสียงดัง ไม่มี
หยุดหายใจ Dx เป็น OSA ใช้ CPAP
PMN: เป็น Asthma ตอน 1 ปี หลังจากนั้น
แข็งแรงดี, ปฏิเสธการแพ้ยา, ได้รับวัคซีน
ครบ และมีพัฒนาการสมวัย

3. Extra-oral examination

4. Intra-oral examination
MMO=1mm

5. OPG

6. Lat ceph

7. PA ceph

8. CXR

9. CT

10. Diagnosis
• Bilateral TMJ Ankylosis
 Lt TMJ  Bony ankyloses type IV
 Rt TMJ  Fibrous ankylosis

11. Treatment plan
Surgery treatment
 Gap arthroplasty at Rt TMJ
 Reconstruction at Lt TMJ with costochondral graft
Postoperative Physiotherapy
 Pateint should be encouraged to start active
exercises of jaw as soon as it can be to lolerated
(mouth gag, finger exerciser)
Follow-up

12. 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.

13. Anatomy

14. Anatomy (Cont.)

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

16. 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

17. Pathophysiology
Truma
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis

18. Pathophysiology
Infection
Degenerative changes
Roughness, limitation
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis

19. Unilateral clinical features
• Mouth opening is very limited
• Asymmetry of face with fullness of the affected side &
relative flattening of the unaffected side.
• Face is deviated towards the affected side.
• Chin is retracted on the affected side & slightly bypass the
midline.
• Slight gliding movement towards the affected side.
• Cross bite is present.
• Well defined antegonial notch on affected side.

20. Bilateral clinical features
• Bird face appearance/ micrognathia.
• No gliding movement neither protrusive nor lateral movement.
• Presence of scar on the chin (possibly due to trauma)
• Class II malocclusion, protrusive incisors & anterior open bite.
• In a long standing case there is atrophy or fibrosis of muscle.
• In congenital case-difficulty of introducing the nipple into the
mouth of newborn infants.

21. Investigations
• For definitive diagnosis & to confirm the extent
of bony growth imaging may be required.
1. Lateral oblique view
2. O. P. G. view
3. Cephalometric radiograph
4. Submentovertex view
5. PA view
6. C T Scan

22. Radiographic features
• Fusion of joint
• Loss of joint space
• Prominent antigonial notch
• Coronoid hyperplasia

23. Sequelae of TMJ ankylosis
• Facial growth distortion
• Nutritional impairment
• Respiratory disorders
• Malocclusion
• Poor oral hygiene
• Multiple carious and impacted teeth

24. Management
• Non surgical management
• Surgical treatment

25. 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

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

27. 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.

28. Gap arthroplastry
 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

29. 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

31. 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

32.  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.

33. Use of costochondral graft
• In children, after the release of the ankylosis. It
is necessary to place a material that will allow
groth
• A costochondral graft is harvested from the 5th
6th or 7th rib
• A costochondral junction about 1.5 cm is
harvested and attached to lateral surface of
ramus of the mandible to reconstruct the ramus
• Cosmetic surgery is carried out at the later date
when the growth of the patient is completed.

34. Complicatipon of costochondral grafting
procedure
1. Second surgical site is necessary.
2. Difficulty in suturing or stablizing the
interpositional material on the medial aspect of
joint.
3. Doner site complication such as pleuritic
pain, pneumothorax.
4. Excessive growth of graft beyond what is
required. This can be minimised by taking not
more than 1.5 cm of costochondral graft.

35. 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
Complications of surgery

36. • 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
Recurrence of TMJ ankylosis