Temporomandibular joint ankylosis

1. DR. AMIT KR.CHOUDHARY
RIMS,IMPHAL

2. Type of joint- synovial joint

3. Upper articular surface - part of temporal bone
1.Articular tubercular
2.Anterior part of mandibular fossa
3.Tympanic plate
Inferior articular surface - head of mandible

6.  FIBROUS CAPSULE
loose above the intra articular disc and tight below it
Synovial membrane lines it
 Lateral temporomandibular ligament
reinforces the capsular ligament
 Sphenomandibular ligament
Remnant of merkel’s cartilage
 Stylomandibular ligament
Thickened part of deep cervical fascia
Separates parotid and submandibular gland

8.  Divides the joint into upper and lower
compartment
 Upper compartment- gliding
 Lower compartment-rotation and gliding
 Periphery of disc attached to fibrous capsule
 Represents primitive insertion of lateral pterygoid
 Prevents friction b/w articular surface
 Proprioceptive fibre present

11.  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.

12.  Affects all age group but more in the first decade of life (0 –
10 years).
 Equal male and female distribution.
 More common in Asian subcontinent.

13.  Bilateral or Unilateral ankylosis
 Fibrous ankylosis or Bony ankylosis
 Intra-articular or Extra-articular ankylosis
 Complete or Partial ankylosis
 True or false ankylosis

14. 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
Others
-Malignancies
-Post radiology
-Post surgery
-Prolonged trismus
Systemic disease
-Small pox
-Ankylosing spondylitis
-Syphilis
-Typhoid fever
-Scarlet fever

15.  Extra-articular ankylosis may be due to enlargement of the
muscles of mastication, the facial nerve, or the coronoid
process.
 Intra-articular ankylosis causes are trauma, infection, and
juvenile rheumatoid arthritis.

16. TRAUMA
Extravasation of blood into the joint space
Haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis

17.  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

19.  Fusion of joint
 Loss of joint space
 Prominent antigonial notch
 Coronoid hyperplasia

20.  Facial growth distortion
 Nutritional impairment
 Respiratory disorders
 Malocclusion
 Poor oral hygiene
 Multiple carious and impacted teeth

21.  The diagnostic modalities for ankylosis of the TMJ include CT
scanning.
 CT with three-dimensional reformatting is especially useful.

22.  Non surgical management
 Surgical treatment

23. 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

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

25.  For patients with early ankylosis
 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.

26.  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.
 There is high recurrence and open
bite deformity.

27.  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.

28.  In patients with severe disease, placement of alloplastic or
autogenous materials after resection of the condyle is the
favored surgical approach.
 The interposition of materials is used to maintain vertical
height and to restore a functional joint.
 A commonly used alloplast has been silicone rubber to
produce a pseudoarticulation.

29.  Autogenous replacement materials includes dermis, fat, fascia
lata, and muscle.
 The costochondral graft harvested from the contralateral sixth
rib is the optimal approach.
 Autologous condylar reconstruction is preferred in the
growing patient and young adult, in whom a prosthetic implant
will probably wear out at some point and need to be replaced.
 The patient needs aggressive physical therapy to maintain
motion of the reconstructed joint space.

31.  Total TMJ reconstruction has
proved safe and effective in
long-term management of
selected patients.
 The prosthesis should be
custom fitted; computer-
aided design and
manufactured.