TEMPOROMANDIBULAR JOINT ANKYLOSIS

Dr. SAIMA GUL POST-GRADUATE TRAINEEORAL AND MAXILLOFACIAL SURGERYHAYATABAD MEDICAL COMPLEX

TEMPOROMANDIBULAR JOINT ANKYLOSIS

Temporomandibular joint is the articulation between squamous part of temporal bone and the head of mandibular condyle.

TMJ ARTICULATION CONSIST OF:

Glenoid fossaArticular eminanceCondyleExternal auditory meatusZygomatic archSigmoid notch

TMJ ANKYLOSIS

TMJ Ankylosis is the fusion of theMandibular condyle with the glenoid fossa , oblitering the normal articulation and immobilizing the mandible.

Causes of TMJ AnkylosisINFEC

INFECTION

Otitis mediaSupurative arthritisParotitismastoiditis

Mechanism of TMJ Ankylosis

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TMJ ANKYLOSIS

Fibrous ankylosisfibro-osseous ankylosisOsseous ankylosis

Al-Hakim , SA Metwali 2003

CLASS I: Includes unilateral & bilatral fibrous ankylosisCLASS II: Includes unilateral or bilateral bony anlylosisCLASS III :Distance between medial pole of condyle and maxillary artery is decreasedCLASS VI: Ankylosed mass appeared fused to base of skull

Topazians STAGING

Stage I : Ankylotic mass limited to condylar process

Stage II: Ankylotic mass extending to the sigmoid notch

Stage III: Ankylosis extending to coronoid process

DIAGNOSIS History

Physical examination

Radiographs

CLINICAL FEATURES

UNILATERAL ANKYLOSISEXTRA-ORAL FEATURES:

Facial asymmetry Microgenia Short posterior facial heightMinimal condylar movements on palpation

BILATERAL ANKYLOSISEXTRA-ORAL FEATURES:

Bird-face deformity / Andy gump deformityConvex facial profileRetrognathic mandibleObtuse cervico-mental angleMarked decreased lower face height

INTRA-ORAL FEATURES:

Midline shift towards effected sideClass II malocclusion Cross-bite (unilateral/ bilateral)Limited mouth openingNeglected oral hygiene with carries & periodontal problems

ASSOCIATED PROBLEMS Interferes with the mastication of food and with nutrition Interference with speech Psychologic problems Prevents oral hygiene and prophylactic careObstructive sleep apnea due to narrowing of oro-pharyngeal airway

RADIOGRAPHS

Orthopantomogram (OPG) Reverse townes view ( PA-face )Lateral cephalogram CT- scan ( axial & coronal view)Magnetic resonance imagingCT- angiogram

RADIOGRAPHIC FEATURES:

Narrowing of joint space in fibrous ankylosisTotal joint space obliteration in bony ankylosisShort ramal heightProminent antegonial notchCrowding in lower teethElongated coronoid process of mandible

ORTHOPANTOMOGRAM (OPG)

Lateral Cephalogram To assessNarrowing of airwayAntero-posterior extensionElongation of coronoidShortened PFHSteep mandibular planeRetrognathia Retrogenia

CT-scan / 3D CT-scanTo assess:Relationship with the base of skull and important structures like Pterygoid platesCarotid canalJugular foramenForamen spinosum

Magnetic rasonance imagingTo assess Meniscus positionFibrous ankylosis

Treatment

TEAM APPROACHMaxillofacial surgeonOrthodontist Anaesthetist Physiotherapist Nutritionist Speech therapistPsychologist Oral hygienist

GOALS OF SURGICAL TREATMENT

Restore mouth openingRestore joint functionAllow for condylar growth (children)Correct facial profileRelieve upper airway obstruction

Treatment protocol

Early & aggressive surgical resection of the ankylotic mass Coronoidectomy + myotomy on the affected side.If still not created enough opening, contralateral coronoidectomy is done. Lining the joint with temporalis fascia or cartilage.

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6. Reconstruction of ramal height. Early post-operative aggressive physiotherapyOrthodontic treatment.Regular long term follow-up Orthognathic surgery

AIRWAY MANAGEMENT

Blind nasal intubationFiber-optic guided oro-tracheal intubationElective tracheostomy

Surgical Approaches To TMJ

Preauricular incision with modificationsPost-auricular Endaural incision Coronal incision Post-ramal

Surgical Options

Different treatment options are availableHigh CondylectomyGap arthroplastyInterpositional arthroplasty

High Condylectomy High condylectomy is the resection of only upper part of condylar head.

It is indicated in cases of fibrous ankylosis where the articular space has not been completely eliminated.

Gap arthroplasty An osteoarthrotomy is performed to remove a slice of bone about 1.5 2 cm in width , which is known as gap arthroplasty

INDICATION:Bony ankylosis

The mouth is forced open with the help of a mouth gag to check the mouth opening -a gap of 1.5 - 2 cm is created & not interposed with any material.

Post-op, this gap is maintained by active physiotherapy to prevent re-ankylosis.

Interpositional arthroplasty

It involves the creation of gap but in addition inserting a barrier between two bony cut ends to minimize chances of re-ankylosis and to maintain the vertical height of ramus.

Interpositional materials

Autogenous materialsHeterogenous materialsAlloplastic materials

Reconstruction options

Autogenous graftsAlloplastic graft Distraction Osteogenesis (latest)

Graft materials

COSTOCHONDRAL GRAFT

Techmedica total joint prosthesisChristensen prosthesis

Kent-vitek prosthesisTechmedica /tmj conceptsLorenz prosthesis

Distraction osteogenesis

Distraction osteogenesis

CONSOLODATION PERIOD , FACIAL PROFILE

3 cm of transport distraction being done

Latest advancement in management

Navigation-aided resection of ankyloting massHolmium-YAG laser with the help of arthroscope for fibrous ankylosisTissue engineered TMJ reconstruction

Post-op treatmentAfter surgery, a pressure dressing is applied with a bandage.A drain is placed.The patient is kept on steroids + antibiotic therapy for 7 to 10 days. After 24 hours the dressing is changed .Active physiotherapy start from 2nd post-op day. Remove skin stitches on 5th- 7th post op day.

Post-op physiotherapy

Physiotherapy is as important as the surgery itself. Post- operatively for minimum for 6 months. Pressure with finger or simple finger exercises to gently force the mouth open initially with tongue blades / acrylic screw / jaw exerciser.

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A mouth gag can be used for forceful mouth opening at a later stage. During physiotherapy, medications can be given to relieve pain and enable movement. Heat application to the joint region prior to exercise permits easy movement by relieving muscle spasm.

TONGUE BLADES EXERCISE

FERGOSSON MOUTH GAG

PASSIVE MOUTH EXERCISER

PRE-OP MOUTH OPENING

INTERPOSITIONAL ARTHROPLASTY WITH ARTICULATING DISK

POST-OP MOUTH OPENING

PRE-OP MOUTH OPENING

INTERPOSITIONAL ARTHROPLASTY WITH TEMPORALIS FASCIA

POST-OP MOUTH OPENING

COMPLICATIONS

Per-op complicationsDifficult intubationDifficult tracheostomy due to smaller trachea Hemorrhage Damage to external auditory meatus.Damage to nerves (zygomatic & temporal branch of facial nerve, auriculotemporal nerve)Damage to glenoid fossa and thus perforation into middle cranial fossa. Damage to parotid gland.Damage to the teeth during opening of the jaws with mouth gag and extubation.

Post-op complicationsExtra-oral scarInfection Open biteAnaesthesia /paresthesia due to nerve damage Weakness of muscles of facial expressionsFreys syndromeExternal auditory meatus stenosisRecurrence of ankylosis

Follow -up Asses airway Facial profileMeasure mouth openingOcclusion Oral hygiene statusNutritional statusPsychologic behaviourNeed for orthodontic treatment/Orthognathic surgeryAny complication and its managementKeep patients record

References :Peter ward booth, stephen A.schendel ,jarg-erich hauseman .Maxillofacial surgery vol II second edition.Neelima anil malik.textbook of oral and maxillofacia surgery 3rd edition.Miloro M, Ghali GE, Larsen P, Waite P. Petersons principles of oral and maxillofacial surgery,volume II. Third edition.Muralee Mohan C. , B. Rajendra Prasad , Smitha Bhat & Shyam S. Bhat. reconstruction of condyle following surgicalcorrection of temporomandibular joint ankylosis: current concepts and considerations for the future. nujhs2014:4(2).Dr Neetu Dabla,1 Dr P Narayana Prasad,2 Dr Arjun Vedvyas,3 Dr Richa Aggarwal. Treatment of Facial Asymmetry and Temporomandibular Joint.Ankylosis by Distraction Osteogenesis: A Case Report.OJON2013:3(2).