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TemporoMandibular Joint Ankylosis TemporoMandibular Joint Hypermobility.

TemporoMandibular Joint Ankylosis

 Definition :
Inability to open the mouth beyond 5-10mm of inter-incisal opening due to fusion of head of the condyle of the mandible with the articulating surface of the glenoid fossa.

Ankylosis, or Anchylosis from Greek bent, crooked.

Classification
1. False ankylosis or True ankylosis. 2. Extra - articular or Intra - articular. 3. Fibrous or bony. 4. Unilateral or bilateral. 5. Partial or complete.

Etiology
False Ankylosis :
1. Muscular Trismus : 2. Muscular Fibrosis : 3. Myositis Ossificans :

4. Tetany : 5. Tetanus : 6. Neurogenic Causes : 7. Trismus Hystericus : 8. Drug Induced :

9. Mechanical Blockade : 10. Fracture of the Zygomatic Arch : 11. Fracture of Mandible : 12. OSMF :

True Ankylosis :
Classified as: Fibrous Ankylosis. Fibro - osseous Ankylosis. Bony Ankylosis. Further, it may be unilateral or bilateral and partial or complete.

Etiology
1. Birth Trauma : 2. Haemarthrosis : 3. Suppurative Arthritis :

4. Rheumatoid Arthritis : 5. Osteomyelitis : 6. Fracture of the condyle :

CLINICAL FEATURES
Clinical manifestations vary according to:
Severity of ankylosis. Time of onset of ankylosis. Duration.

 Pain. Reduced mouth opening . Difficulty or inability in mastication. food.

Features :
Receding chin. Malocclusion. Multiple Impacted teeth. The maxilla may be narrow and protrude. Ante - gonial notching.

In Bilateral Ankylosis :
Bird face deformity + micro gnathic mandible Inability to open mouth + inability to masticate Class II malocclusion Ante - gonial notching Poor oral hygiene Severe malocclusion with crowding + protrusive upper anterior teeth + anterior open bite

In Unilateral Ankylosis :
Facial asymmetry with affected side. Chin is deviated to the ankylosed side. Ante-gonial notch on the affected side Minimal condylar movements on palpation. Class II malocclusion on affected side and cross bite may be seen

Problems associated with Ankylosis

1. Interferes with the mastication of food and with nutrition 2. Prevents oral hygiene and prophylactic care. 3. Dental care. 4. Absence of normal development of the jaw . 5. Disturbance of normal eruption of the teeth.

Diagnosis
Diagnosis is based on:
1. History of infection or trauma 2. Findings at clinical examination 3. Radiological findings

Radiographic Examination
Orthopantomograph

PA Mandible

Lateral view of Mandible

 CT Scan/3D CT Scan

3D CT SCAN showing Bony Ankylosis

Coronal CT Scan showing Bilateral TMJ Ankylosis

 Cone Beam 3D CT Scan

In fibrous ankylosis :
Evidence of destructive. Proliferative changes seen in bony compartments of TMJ. Haziness or narrowing of joint space.

In bony ankylosis :
Overall obliteration of joint space. Antegonial notching anterior to the angle of mandible. Elongation of coronoid process.

What happens if Ankylosis is left untreated ?

Normal growth & development of face is affected. Nutritional impairment. Speech impairment. Sleep apnoea in Bilateral Ankylosis. Malocclusion. Poor Oral hygiene. Multiple Carious and Impacted teeth.

MANAGEMENT OF ANKYLOSIS

Aims and Objectives of Surgery

1. Release of ankylosed mass and creation of a gap to mobilize the joint. 2. Creation of a functional joint. - To improve patient's nutrition. - To improve patient's oral hygiene. - To carry out necessary dental treatment. 3. To reconstruct the joint and restore the vertical height of the ramus.

4. To prevent recurrence. 5. To restore normal facial growth pattern

6. To improve esthetics and rehabilitate the patient.

Pre Surgical Considerations

Techniques such as blind nasal, fibre-optic or retrograde intubation may be employed.

Blood loss may be significant at the time of surgery especially in children.

KABANS PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS

1.Early surgical management. 2.Aggressive total excision of the ankylotic mass. 3.Coronoidectomy + myotomy on the affected side to eliminate temporalis muscle restriction. 4.Lining with temporalis muscle/fascia 5.If steps 1 + 2 + 3 do not create enough opening, opposite side coronoidectomy is done.

6.Reconstruction of Ramal height with Costochondral graft. 7. Early post-operative mobilisation and aggressive physiotherapy for at least 6 -12 months.

8. Regular long term follow-up.

9. Esthetic /orthognathic surgery to be carried out as

a secondary procedure, when growth has completed.

SURGICAL PROCEDURE

Surgical Procedures :
1. 2. 3. 4. Use of Brisement Force. Condylectomy. Gap Arthroplasty. Interpositional Arthroplasty.

Use of Brisement Force

Oldest method. The jaw is forced open by means of a mouth gag and mobilized as much as possible by forceful manipulation. Indicated in Fibrous Ankylosis or immobility caused by muscle Spring loaded Bell Excerciser spasms or fibrosis.

Condylectomy and Arthroplasty

Esmarch 1851
Murphy 1913 Blair 1928

Condylectomy
Indication:
1.Degenerative inflammatory Disorders. 2.Malunited condylar fractures with limitation of motion and pain during mastication. 3.Terminal Stages of Internal Derangement. 4.Fibrous Ankylosis.

Condylectomy
Patient Preparation :
1> Temporal shaving. 2> Patient placed in supine position with head ring. 3> Anaesthetic is safely secured. 4> Face is left clear of the other drapes. 5> Ear canal is cleansed and covered.

Approach :
1> Capsule is opened via an inverted L incision. 2> Anterior and posterior borders of the condylar neck.

Removal of Ankylotic mass :

Cut is marked in a 45 angle from the sigmoid notch to the posterior border of the ramus. Osteotomy is completed on the lateral cortex, and the inner cortex is left intact . Pulling of the fragment not to be attempted.

 Dissection around the mass anteriorly and posteriorly. Bone mass now can be removed in total or in piecemeal. Cronoidectomy is done if indicated. Smoothening of all the bone surfaces. Haemostasis is achieved.

 IMF done after achievement of occclusion. Edentulous patients Gunning splints is be used. Decision of Reconstruction is now taken.

Complications

Loss of vertical height of the ramus. In case of bilateral condylectomy, it may create an anterior open bite. In unilateral cases, there may be deviation of the jaw on opening.

Gap Arthoplasty
Bone of about 1.5 to 2 cm in width is removed. Care should be taken while removing bone from the medial aspect of the TM Joint. Mouth is opened to check the opening 1.5 - 2 cms & not interposed with any material. Post-op, this gap is maintained by active physiotherapy to prevent re-ankylosis. It may be necessary to osteotomise the coronoid process also.

Interpositional Arthroplasty
Interpositional arthoplasty is similar to the gap arthroplasty but the Gap is Filled by a Interpositional Graft. Alloplastic Materials : Metallic Tantalum Plate, Titanium, Gold. Non Metallic Silastic, Teflon, Acrylic, Ceramic. Autogenous Materials : Temporalis muscle Temporalis fascia, Skin grafts. Auricular cartilage.

Reconstruction of TMJ

Alloplastic Prosthesis
Kent-Vitek Synthes Derlin-Timesh Christensen Biomet -Lorenz

Kent-Vitek

Synthes

Derlin-Timesh

Christensen

Biomet-Lorenz

Postoperative Care
1> Pressure dressing is applied by Dynaplast . 2> The patient is kept on Antibiotic therapy for 7 to 10 days.

3> Immobilization of the jaw by means of intermaxillary elastics is recommended for the first 7- 10 days.
4> Patient is given Physiotherapy.

Postoperative Physiotherapy

Important Phase of Treatment . Patient should be encouraged to start active exercises of the jaws as soon as it can be tolerated. A mouth gag can be used for forceful mouth opening at a later stage. Medications can be given to relieve pain and enable movement. Heat application.

Complications
During Anaesthesia :

1.Aspiration of blood clot or foreign body during extubation as throat cannot be packed prior to surgery. 2.Danger of falling back of tongue and obstructing airway.

During Surgery :
Hemorrhage. Damage to External Auditory Meatus. Damage to Zygomatic and temporal branch of facial nerve. Damage to Glenoid fossa and thus perforation into Middle Cranial Fossa. Damage to Auriculotemporal nerve. Damage to Parotid gland.

During Post Operative Period :

1.Infection. 2.Open bite. 3.Recurrence of Ankylosis.

TemporoMandibular Joint Hypermobility and Dislocation

TMJ Hypermobility
Definition : A self reducing partial dislocation of TMJ, during which condyles passes anterior to the articular eminence.
Petersons Principal of OMFS Vol 2, Pg No. 1044 .

Etiology
Yawning. Vomiting. Wide biting. Seizure Disorders. Trauma:

Intubation during General Anaesthesia. Endoscopy. Prolonged Dental procedure.

 Connective Tissue Disorders :

Ehlers-Danlos Syndrome. Marfan Syndrome.

Internal Disc Derangements..

Management
Conservative Management:
Prolotherapy. Immobilisation of Jaws.

Surgical Management :
Capsule Tightening Procedure. Creation of Mechanical Obstruction. Eminectomy.

Conservative Management

 Hackett 1939. Mechanism of Action : Re initiation of inflammatory process leading to fibroblast proliferation. Most commonly used agents : Sodium Tetradecyl Sulphate Sodium Morrhuate. 12 % Dextrose Solution.

Prolotherapy

Frequency of Injection
Two-week, four-week, and six-week intervals, resulting in four injection appointments over a total of 12 weeks.

Post Injection Instructions

Soft diet. Avoidance of prescription of antiinflammatory medications. Avoidance of Ice Application. Analgesics : Acetaminophen / Opoid Analgesic.

Contraindications
Allergy or sensitivity . Active infection or malignancy in the area to be injected. Bleeding Disorders.

Immobilisation of Jaws
Period : 3 4 weeks . Immobilisation can be achieved by : Arch Bars with Elastics.

Surgical Management

Capsule Tightening
1. Capsulorraphy . 2. Placement of vertical incision. 3. Re inforcement of capsule.

Mechanical Obstruction
1. 2. 3. 4. Le Clerc Procedure. Dautery Procedure. Bone Graft Placement. Pin Placement.

Le Clerc Procedure
Le Clerc and Girald in 1943. Technique : Approach :Preauricular incision. Dissection of the zygomatic arch is performed. Vertical osteotomy is done on the arch . Arch is moved inferiorly.

Dautery Procedure
Gosserez and Dautrey 1964. Posterior-anterior slanting osteotomy of the eminence. Commonly used.

 Bone Graft Placement : Mayor

Pin Placement :
Findlay

Eminectomy
Myrhaug 1951. Removal of a portion of the articular tubercle and eminence Concerns : Damage to contiguous tissues. Clicking and crepitation Recurrent dislocation

Refference
Principle of OMFS Vol 2 Michael Miloro. Colour Atlas Of TMJ Surgery Peter Quinn. TMD Evidence based Treatment Laskin. Management Of TMD and Occlusion J Okkeson. Maxillofacial Surgery Vol 2 Peter Ward Booth.