Tmj ankylosis overview

CRANIOMANDIBULAR
JOINT(CMJ) ANKYLOSIS
Presenter: Dr Kiprop, Jonathan.
Supervisor: Dr Butt
University of Nairobi ISO 9001:2008 1 Certified http://www.uonbi.ac.ke

∗ CMJ anatomy overview
∗ Definition of CMJ ankylosis
∗ Etiology
∗ Classification
∗ Clinical presentation
∗ Management strategies
∗ Complications
∗ Current understanding…presentation of Prof Guthua
Presentation Outline

∗ 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

Anatomy of CMJ; Components

∗ 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…

∗ 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…

∗ Stability factors
 Static..
 Dynamic
∗ Movements …produced by attachments of muscles
of mastication
 Protrusion and retraction
 Elevation and depression
 Lateral excursions
Athrokinematics of CMJ

∗ 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

∗ 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

∗ Greek terminology meaning ‘stiff joint’
∗ Inability to open the mouth either due to fibrous or
bony union of the head of condyle and the glenoid
fossa.
∗ Results in Hypomobility or immobility
∗ Jaw functions get affected
∗ Downward trend in the west but incidence still high in
India and Africa
CMJ Ankylosis

Classification of Ankylosis

Grading of CMJ ankyloses

∗ Restricted mouth opening…trismus
∗ Facial asymmetry esp. in unilateral ankylosis. Bilateral
maybe deceptively symmetrical
∗ Mandibular micrognathia
∗ Bird face deformity, bird’s beak deformity.
∗ Poor oral hygiene and rampant caries
∗ Absence of condylar movements
∗ Malocclusion esp. class 2 with posterior cross bite and
anterior open bite.
Clinical Features

• Fusion of joint …mushroom deformity
• Loss of joint space
• Prominent antegonial notch
• Coronoid hyperplasia
Radiographic features

∗ Facial growth distortion… Aesthetics
∗ Nutritional impairment
∗ Respiratory disorders
∗ Malocclusion
∗ Poor oral hygiene
∗ Multiple carious and impacted teeth
Sequelae of CMJ Ankylosis

∗ 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

Principles of Management
∗ Early surgical intervention
∗ Elaborate resection
∗ Early mobilization
∗ Aggressive physiotherapy for at least 6 months post
operatively

∗ Ipsilateral coronoidectomy and contralateral
coronoidectomy for longstanding ipsilateral CMJ
ankylosis
∗ Psychological rehabilitation
Principles of Management

∗ Non-surgical management vs Surgical treatment
∗ Surgical Management
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty
4. Total joint reconstruction
Management Strategies

• 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

∗ 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

∗ 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

∗ Re-ankylosis
∗ Resorption
∗ Overgrowth
∗ Fracture
∗ Pain
Post-op. Complications

∗ 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

∗ 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

∗ 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

∗ 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

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

Thank you.

Tmj ankylosis overview

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