tmj ankylosis
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TEMPOROMANDIBULAR JOINT ANKYLOSIS AND ITS MANAGEMENT
•INTRODUCTION
•CLASSIFICATION
•INCIDENCE
•AETIOLOGY
•PATHOPHYSIOLOGY
•CLINICAL FEATURES
•SEQUELAE OF TMJ ANKYLOSIS
•MANAGEMENT
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.
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
CLASSIFICATIONS
•Bilateral or Unilateral ankylosis
•Fibrous ankylosis or Bony ankylosis
•Intra-articular or Extra-articular ankylosis
•Complete or Partial ankylosis
•True or false ankylosis
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
PATHOPHYSIOLOGY
TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
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
RADIOGRAPHIC FEATURES
Fusion of joint Loss of joint space Prominent antigonial notch Coronoid hyperplasia
SEQUELAE OF TMJ ANKYLOSIS
•Facial growth distortion
•Nutritional impairment
•Respiratory disorders
•Malocclusion
•Poor oral hygiene
•Multiple carious and impacted teeth
MANAGEMENT
Non surgical management
Surgical treatment
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 ramusTo prevent recurrenceTo restore normal facial growth pattern
Procedures
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty
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.
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
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
MATERIALS USED IN INTERPOSITIONAL ARTHROPLASTY
Autogenous Heterogenous Alloplastic
I. Temporalis muscles
II. Temporalis fascia
III. Fascia lata
IV. Cartiligenous graftsCostochondralMetatartsalSternoclavicularAuricular 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
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.
Complications of the surgery
Intra-OperativeHaemorrhage (damage of any superficial temporal vessels, transverse facial artery, etc)Damage to the external auditory meatusDamage to the Zygomatic and temp. branch of facial nerveDamage to the Auriculotemporal nerveDamage to the Parotid glandDamage to the teeth
Post Operativeinfection open bite
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
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