temporo mandibular joint and ankylosis treatment

1. Pooja kaloniya
48/2009

2.  THE TEMPOROMANDIBULAR JOINT IS ALSO
KNOWN AS THE CRANIOMANDIBULAR JOINT or
BILATERAL DIARTHROIDIAL.
 IT IS THE ARTICULATION BETWEEN THE
SQUAMOUS PART OF THE TEMPORAL BONE AND
THE HEAD OF THE MANDIBULAR CONDYLE.
 IT IS ALSO CONSIDERED AS COMPLEX JOINT
BECAUSE IT INVOLVES TWO SEPARTE SYNOVIAL
JOINT, IN WHICH THERE IS A PRESENCE OF
INTRACAPSULAR DISC OR MENISCUS.

3.  GLENOID FOSSA
 ARTICULAR EMINENCE
 CONDLYE
 SEPARATING DISC
 JOINT FIBROUS
CAPSULE
 EXTRACAPSULAR
LIGAMENTS

4.  COMPRISES OF
 Temporomandibular joint
 Masticatory and accessory
muscles
 Occlusion of teeth
 The function is governed
by sensory and motor
branches of the third
division of trigeminal
nerve.

5.  MANDIBULAR FOSSA(GLENOID)
 IT HAS AN ANTERIOR ARTICULAR AREA BY THE INFERIOR
ASPECT OF TEMPORAL SQUAMA.
 THE FOSSA IS LINED BY A DENSE AVASCULAR
FIBROCARTILAGE.
 ARTICULAR EMINENCE
 IT SEPARATES THE ARTICULAR SURFACE OF THE FOSSA
LATERALLY FROM THE TYMPANIC PLATE.
 THE EMINENCE IS COVERED BY DENSE, COMPCT, FIBROUS
TISSUE THAT CONSISTS PRIMARILY OF COLLEGEN WITH
AFEW FINE ELASTIC FIBERS
 TMJ CAPSULE
 IT IS A THIN SLEEVE OF FIBROUS TISSUE INVESTING THE
JOINT COMPLETY
 IT IS A FUNNEL SHAPED CAPSULE,WHICH BLENDS WITH THE
PERIOSTEUM OF THE MANDIBULAR NECK AND ENVELOPS
THE MENISCUS

7.  IT REINFORCE THE TMJ CAPSULE
 IT EXTENDS DOWNWARD & BACKWARD FROM THE
ARTICULAR EMINENCE TO THE EXTERNAL AND
POSTERIOR SIDE OF THE CONDYLAR NECK
 ITS POSTERIOR FIBER ARE UNITED WITH THE
CAPSULAR FIBERS
 THIS LIGAMENT IS COMPOSED OF COLLAGENOUS
FIBERS THAT HAVE SEPIFIC LENGTH AND POOR
ABILITY TO STRETCH, HENCE IT MAINTAINS THE
INTEGRITY AND LIMITS THE MOVEMENT OF TMJ
 IT MAINLY LIMITS THE ANTERIOR EXCURSION OF THE
JAW AS WELLAS PREVENTS POSTERIOR DISLOCATON ,
ALSO CALLED CHECK LIGAMENT.

8.  SPHENOMANDIBULAR
LIGAMENT
 A FLAT BAND ARISING
FROM THE APHENOID
SPINE AND
PETROTYMPANIC
FISSURE, RUNS
DOWNWARDS AND
MEDIAL TO THE TMJ
 INTERNAL MAXILLARY
ARTERY AND
AURICULOTEMPORAL
NERVE LIES B/W IT
AND MANDIBULAR
NECK
STYLOMANDIBULAR LIGAMENT
IT IS DENCE THICK BAND OF THE DEEP CERVICIVAL FASIA
EXTENDING FROM THE STYLOID PROCESS TO THE
MANDIBULAR ANGLE.

9.  THE MENISCUS DIVIDES THE TWO ARTICULAR SPACE
INTO TWO COMPARTMENT
 LOWER OR INFERIOR COMPARTMENT- condylodiscal complex
b/w the condyle and the disc
 UPPER OR SUPERIOR COMPARTMENT – b/w disc and the glenoid
fossa.
 The disc is biconcave in the sagital section.
 The superior surface is concavoconvex to match the anatomy of
the glenoid fossa.
 The inferior surface is concave to fit over condylar head
 The disc blends medially and laterally with the capsule, which is
attached to the medial and lateral poles of the condyle.
 Anteriorly the disc is attached to the articular eminence above &
to the articular margin of the condyle below.
 Posteriorly disc is attached to the posterior wall of glenoid fossa

11.  The disc is a meshwork of firmly woven avascular fibrous
connective tissue & it is also noninnervated with possible
exceptions around its periphery.
 These collagen fibers impart flexibility to the disc.
 The disc is designed to transmit the forces generated
through the condyle to the articular eminence.
 It promotes lubrication energy absorption and joint
range of motion. It acts as a main shock absorber
enabling the articulating bones to move against each
other with minimum friction and heat production.
 Disc has Avery little potential for repair after inult.

12.  Lateral aspect is supplied by
superfical temporal branch
of the external caroid artery.
 Rich vascular supply to the
deep and posterior aspect of
retrodiscal capsular part by
deep auricular, posterior
auricular & masseteric
branches of the internal
maxillary artery
 Vascular supply to the lateral
pterygoid muscle also
supplies to the head of the
condyle by penetration of
numerous nutrient foramina
vessels

13.  THE MANDIBULAR NERVE,
THE THIRD DIVISION OF
THE FIFTH CRANIAL NERVE
INNERVATES THE JAW
JOINTS:-
 The largest is the
auriculotemporal nerve which
supplies the posterior, medial
and lateral part of the joint
 Masseteric nerve
 A branch from the posterior
deep temporal nerve, supply
the anterior parts of the joint

14.  The movements of tmj are manifold. It is ginglimus
diarthroidai type of joint, as it sis capable of rotating
around more than one axis and is capable of
translatory movement.
 MUSCLE FUNCTION- The functions of the muscles of
mastication in jaw movement are coordinated and
balanced by normal muscle tone.
 The muscle of mastication (medial and lateral
pterigoid,masseter, buccinator, mylohyoid, temporalis
& anterior belly of the digastric) are assisted by the
suprahyoid and digastric muscle.

16.  JAW OPENING It is dominated by daigastric muscle
contraction, which depress the body of the mandible.
This action is assisted by the suprahyoid, sternohyoid
and geniohyoid muscles.
 JAW CLOSURE It is accomplished by the simultaneous
contraction of the masseter, medial pterigoid muscles.

17.  PROTRUSIVE MOVEMENT It requires equal
simultaneous contracture of lateral and medial
pterygoid muscle.
 RETRUSION It is brought about by posterior fibers of
temporalis muscles, assisted by middle and deep parts
of the masseter, digastric and geniohyoid muscles.
 LATERAL MOVEMENT These are carried out by
unilateral contracture of medial and lateral pterygoid
of each side acting alternatively.

20.  Intra –articular origin or intrinsic disorder
 Extra –articular origin or extrinsic disorder

21.  MASTICATORY MUSCLE DISORDER
 Protective muscle splinting
 Masticatory muscle inflamation
 Masticatory muscle spasm
 PROBLEMS DAT RESULT FROM EXTRINSIC TRAUMA
 Traumatic arthritis
 Fracture
 Internal disc derangement
 Tendonitis
 Contracture of elevator muscle

22.  TRAUMA
 Dislocation, subluxation
 Haemarthrosis
 Intracapsular fracture, extracapsular fracture
 INTERNAL DISC DISPLACEMENT
 Anterior disc displacement with reduction
 Anterior disc displacement without reduction
 ARTHRITIS
 Osteoarthritis
 Rheumatoid arthritis
 Juvenile rheumatoid arthritis
 Infectious arthritis

23.  DEVELOPMENTAL DEFECTS
 Condylar agenesis or aplasia- unilateral/bilateral
 Bifid condyle
 Condylar hypoplasia
 Condylar hyperplasia
 ANKYLOSIS
 NEOPLASM
 Benign tumours
 Malignant tumours

24. Surgical access to the tmj is an exacting procedure.
Tmj has got close proximity to the main trunk of the facial
nerve with its branches in the temporal and facial areas
It has also got close proximity to the auriculotemporal nerve
and the abundant vascular supply

25.  ADVANTAGES
 Uniform predictability of anatomic exposure &
avoidance of a salivary fistula.
 Negligible hemorrage
 No distortion of anatomic landmarks
 DISADVANTAGES
 Infection involving the external auditory canal
 Paresthesis of the external pinna
 Small surgical exposure with poor access and visibility

27.  ADVANTAGES
 Excellent cosmesis
 Excellent lateral and posterior exposure with
intermediate anterior exposure
 DIADVANTAGES
 Limited access
 Possibility of meatal stenosis

29.  ADVANTAGES
 Excellent cosmesis
 Excellent visibility and accessibility
 DISADVANTAGES
 Close proximity of the posterior facial vein and trunk of
the facial nerve
 Proximity of the posterior border of the parotid gland
 Ideal approach to the condyle neck and ramus

31.  ADVANTAGES
 Inconspicuous location of the incision
 Standard approach to the TMJ
 DISADVANTAGES
 The dissection follows a route through an area which is
rice in nerve and vascular supply.
 BLAIR AND IVY INCISION
 THOMA;S ANGULATED INCISION
 AL- KAYAT AND BRAMLEY

33. Blair’s Inverted
Hockey Stick
Incision
Thoma’s Angulated
Incision
Dingman’s
Incision
Popowich &
Crane Incision

34.  ADVANTAGES OF POPWICH’S
MODIFICATION
 REDUCTION IN INCIDENCE OF FACIAL
NERVE PALSY
 DECEASED HAEMORRHAGE
 IMPROVED VISIBILITY
 GOOD COSMETIC RESULTS
 REDUCTION IN TOTAL OPERATION
TIME
 AVOIDANCE OF AURICULOTEMPORAL
NERVE ANAESTHESIA
 REDUCTION IN POSTOPERATIVE
OEDEMA AND DISCOMFORT

35. MANAGEMENT

36.  It is a greek terminology meaning “STIFF JOINT”
 The jaw function gets affected because of immobility
of the joint.
 Hypomobility to immobility of the joint can lead to
inability to open the mouth from partial to complete.
 Onset is usually seen before the age of 10 years.

38.  FALSE ANKYLOSIS OR TRUE ANKYLOSIS
 EXTRA –ARTICULAR OR INTRA –ARTICULAR
 FIBROUS OR BONY
 UNILATERAL OR BILATERAL
 PARTIAL OR COMPLETE

39. Trauma
- At birth (with forceps)
- Haemarthrosis
- Blow to the chin (causing haemarthrosis)
- Condylar fracture
- congenital
Infections and Inflammatory
- Rheumatoid Arthritis
- Septic arthritis
- Otitis media
- Mastoditis
- Parotitis
- Osteomyelitis
- Osteoarthritis
- Tonsillitis
Systemic disease
- Small pox
- Ankylosing spondylitis
- Syphilis
- Typhoid fever
- Scarlet fever
Others
- Malignancies
- Post radiology
- Post surgery
- Prolonged trismus
Rare causes
- Polyarthritis
- measles

40. TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
PATHOPHYSIOLOGY

41.  It depends more upon clinical examination, rather
than the diagnostic test.
 Restricted or nil oral opening is seen.
 Patient will complain of difficulty in mastication.
 Protrusive movements are not possible on the involved
side.
 Partial mobility or complete immobility of the condyle
is readily noticed.
 Pain is totally absent
 In young patient a nature of facial deformity will help
to differentiate b/w unilateral and bilateral
involvement

42.  IT VARY ACCORDING TO:
 Severity of ankylosis
 Time of onset of ankylosis
 Duration
 EARLY JOINT INVOLVEMENT- less than 15 years:
severe facial deformity and loss of function
 LATER JOINT INVOLVEMENT- after the age of
15years: facial deformity marginal or nil but functional
loss is severe.
 Those patient in whom ankylosis develops after full
growth completion have no facial deformity.

43.  Obvious facial asymmetry
 Deviation of the mandible and chin on the affected side
 The chin is receded with hypoplastic mandible on the
affected side
 The appearance of the flatness and elongaltion on the
unaffected side
 The lower border of the mandible onthe affected side hass
a concavity that ends in a well- defined antegonial notch
 In unilateral ankylosis some amount of oral opening may
be possible. Interincial opening will vary depending on
whether it is fibrous or bony ankylosis
 Cross bite may be seen
 Classic angles malocclusion on the affected side plus
unilateral posterior cross bite on the ipsilateral side seen
 Condylar movements are absent on the affected side

45.  Inability to open the mouth progresses by gradual decrease in
interincisal opening. The mandible is symmetrical but
micrognathic.The patient develops typical 'bird face' deformity
with receding chin.
 The neck chin angle may be reduced or almost completely absent
 Antegonial notch is well defined bilaterally
 Classii malocclusion can be noticed
 Upper incisors are often protrusive with anterior open
bite.Maxilla may be narrow
 Oral opening will be less than 5mm or many times there is nil
oral opening
 Multiple carious teeth with bad periodontal health can be seen
 Severe malocclusion, crowding can be seen and many impacted
teeth may be found on the x-rays.

47.  History of trauma, infection, etc
 Clinical finding
 Radiographic finding- are important in arriving at a final daignosis
 Orthopantomograph- will show both the joints picture which can
be compared in unilateral cases.
 Lateral oblique view- will give anteroposterior dimension of the
condylar mass. Elongation of coronoid process can be seen.
 Cephalometric radiograph- is taken to evaluate the associated
skeletal deformities
 Posteroanterior radiograph- will reveal the medio lateral extent
of the bony mass. It will also highlight the asymmetry in unilateral
cases
 CT scan- very helpful guide for surgery. Relation to the medial
cranial fossa, the anteroposterior width, mediolateral depth can be
assessed. Any presence of fractured condylar head on the medial
aspect of ramus can be located

48.  FIBROUS ANKYLOSIS
 Reduced JOINT SPACE AND HAZY APPEARANCE CAN
BE SEEN.
 But, still the normal anatomy of the head and glenoid
fossa can be appreciated.
 BONY ANKYLOSIS
 Complete OBLITERATION OF JOINT SPACE NORMAL
TMJ ANATOMY IS DISTORTED.
 Deformed condylar head or complete bony
consolidation replacing the joint space can be seen.
 Elongation of the coronoid process onthe side of
hypomobility will be seen.

49.  Normal facial growth and development affected.
 Speech impairment.
 Nutritional impairment.
 Respiratory distress, especially in bilateral involvement
with severe micrognathia.
 Malocclusion.
 Poor oral hygiene.
 Multiple carious and impacted teeth.

50.  Release of ankylosed mass and creation of a gap to
mobilize the joint
 Creation of a functional joint
 To improve patient's nutrition
 To improve patient's oral hygiene
 To carry out necessary dental treatment
 To reconstruct the joint and restore the vertical height
of the ramus.
 To prevent recurrence.
 To restore normal facial growth pattern.
 To improve esthetics and rehabilitate the patient.

51. Early surgical intervention
 Aggressive resection: a gap of atleast 1- 1.5cm should be
created. Special attention should be given to fusion on the
medial of the ramus.
 Ipsilateral coronoidectomy and tempralis myotomy:
in most of these cases there is always association of
elongated coronoid process. After carrying out gap
arthoplasty. The coronoidectomy on the same side should
be carried out either separately or in combination with
the gap arthroplasy cut from the same etraoral incision.

52.  Lining of the glenoid fossa region with temporalis
fascia
 Reconstruction of the ramus with a costochondral
graft.
 Early mobilization and aggressive physiotherapy for
the period of at least six months postoperatively
 Regular long-term follow-up
 To carry to cosmetic Surgery at the later date when the
growth of the patient is completed
 Release of the jaw movements is quite dramatic, upon
competion of coronoid rather than release it and allow
it to be pulled up superior process is removed, there is
potential for reankylosis after reattachment.

53.  Most surgical procedures can be done through a
preauricular incision alone.
 The popwich's incision is chosen for its obvious
advantages
 Whenever required additional submandibular incision
can be used for fixation of the graft.
I : condylectomy
II : gap arthroplasty
III : interpositional arthroplasty

54.  It is advocated in cases of fibrous ankylosis, where
joint space is obliterted with deposition of fibrous
bands , but there is not much deformity of the
condylar head.
 Radiologically and clinically after surgical exposure
one can see the demarcation between the roof of the
glenoid fossa and the head of the condyle.
 The procedure can be done via preauricular incision
 The unilateral condylectomy tends to cause devation
of the mandibule towards the operated side on oral
opening and if bilateral, anterior open bite will be
caused as a result of the loss of the height in the
vertical rami.

55.  Therefore. When the site of the fused joint is
mobilized via condylectomy. Then after recontouring
by arthroplasty, an alloplastic material can be used to
maintain the joint space, satisfactory occlusion and
joint movement.

56.  In the extensive bony ankylosis, a broad,thick area of
bone deposition obliterates the entire joint, sigmoid
notch and coronoid process
 Identification of the previous joint structure is
impossible and mobilization at level of joint become
difficult
 In this operation the level of section is below that
previous joint space
 The section consist of two horizontal osteotomy cuts
and removal of a bony wedge for creation of a gap
between the roof of the glenoid fossa and ramus.
 Minimum gap of 1cm is recommended to pervent
reankylosis

57.  It involves the creation of gap , but in addition a
barrier is inserted between the cut bony surfaces to
minimize the risk of recurrence and to maintain the
vertical height of the ramus

58.  Tamporalis fascia along with a varying thickness of
temporalis muscle may be harvested as an axial flap
based on the middle and deep temporal arteries and
veins
 The dependable blood supply, the proximity to the tmj
and the ability to alter the arc of rotation by basing the
flap inferiorly or posteriorly, makes this a versitile flap
for lining the glenoid fossa.
 It is used as an interpositional material after release of
ankylosis of tmj.

59. Basic 3 goals
1. To replicate structurally normal joint anatomy
2. To provide functional articulation
3. To establish an area , where adaptive growth can
occurs.

60.  Costochondral graft is harvested through the infra-
mammary incision
 Either 5th, 6th, or 7th rib is harvested.
 Costochondral junction of rib is chosen along with
some amount of length of the rib.
 The length of the total graft will depend on the height
of ramus to be restored
 Minimum of 1.5cm of costochondral junction should
be included in the graft
 The graft should be fixed on the lateral aspect of the
rammus with the screws.
 A minimum gap of 0.5 - 1 cm should be kept between
the graft and the glenoid fossa side, so that free
movement is possible without any friction

62.  Increased operating time
 Additional surgical site
 Donor site morbidity
 Graft over growth
 Possible potential for reankylosis

63.  DURING ANAESTHESIA
 As the patient cannot open the mouth, awake blind
intubation has to be done, where patients cooperation is
required, which is very difficult to obtain from younger
group of patients
 Because of small mandible and altered position of the
larynx .intubation poses a problem
 Aspiration of blood clot tooth or foreign body during
extubation as throat cannot be packed prior to surgery
 Danger of falling back of tongue and obstructing airway
is always there after extubation

64.  DURING SURGERY
 Haemorrage due to damage to any of the superficial
temporal vessels, transverse facial artery, inferior
alveolar vessel and internal maxillary vessels, pterygoid
plexus of veins
 Damage to external auditory meatus
 Damage to zygomatic and temporal branch of facial
nerve
 Damage to glenoid fossa and thus leading entry into
middle cranial fossa
 Damage to auriculotemporal nerve
 Damage to parotid gland
 Damage to the teeth during opening of the jaws with jaw
stretcher
 DURING POSTOPERATIVE FOLLOW-UP
 Infection
 Open bite
 Recurrence of ankylosis

65.  An inadequate gap created between the fragments
 Missing on the medial condylar stump and leaving it
behind
 Fracture of the costochondral graft
 Loosening of the costochondral graft due to
inadequate fixation to the ramus
 Inadequate coverage of the glenoid fossa surface
 Inadequate postoperative physiotherapy
 Higher osteogenic potential and periosteal osteogenic
power may be responsible for high rate of recurrence
in children