TEMPOROMANDIBULAR JOINT ANKYLOSIS AND ITS MANAGEMENT

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TEMPOROMANDIBULAR JOINT ANKYLOSIS AND ITS
MANAGEMENT

• BY
• ONYIA Nonso Emmanuel
• SCHOOL OF DENTISTRY
• UNIVERSITY OF BENIN

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OUTLINE

• INTRODUCTION
• CLASSIFICATION
• INCIDENCE
• AETIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• HISTHOPATHOLOGY
• SEQUELAE OFTMJ ANKYLOSIS
• MANAGEMENT

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INTRODUCTION

• Temporomandibular joint,
• (TMJ), an essential joint of the face, required
  for speech and nutrition a synovial joint formed
  by the mandibular fossa of the temporal bone and
  the head of the condyle of the mandible with an
  intervening articular disc. The joint surface is
  completely covered by a thick fibrous capsule
  that allows for range of movements.
• 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.

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INTRODUCTION
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CLASSIFICATIONS

• Bilateral or Unilateral ankylosis
• Fibrous ankylosis or Bony ankylosis
• Intra-articular or Extra-articular ankylosis
• Complete or Partial ankylosis
• True or false ankylosis

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INCIDENCE

• Affects all age group but more in the first
  decade of life (0 10 years)
• Theres equal male and female distribution
• Almost all cases are unilateral.

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AETIOLOGY
Trauma At birth (with forceps) Blow to the chin (causing haemarthrosis) Condylar fracture 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
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PATHOPHYSIOLOGY
TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis
Extra-capsular ankylosis
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Pathophysiology contd

• Intra-capsular ankylosis
• Theres destruction of the meniscus and
  flattening of the temporal fossa
• thickening and flattening of the condylar head
  and a narrowing of the joint space.
• Opposing surfaces then develop fibrous adhesions
  that inhibit normal movements and finally, may
  become ossified.

• Extra-capsular ankylosis
• Theres an external fibrous encapsulation with
  minimal destruction of the joint itself.

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CLINICAL FEATURES

• Inability to open the jaws
• In unilateral ankylosis, the lower jaws shifts
  towards the affected side on opening of the mouth
• In severe cases, there is complete immobilization
• There may be Abnormal forward protrusion of the
  mandible as the excess tissues occupies the space
• Facial deformity
• Others are related to the underlying cause of the
  ankylosis
• Fever
• Pain
• Other bones and joints deformities

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CLINICAL FEATURES
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CLINICAL FEATURES
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clinical features contd
Fibrous Ankylosis Produced by adhesions within the TMJ affecting the fibrous components Bony ankylosis The union of bones of the TMJ by proliferation bone cells, resulting in immobility of the joint
Not usually associated with pain Limited range of motion on opening Deviated to the affected side Limited laterotrusion to the contralateral side No radiographic findings other that absence of ipsilateral condylar translation Not usually associated with pain More marked limitation on opening Theres more marked ipsilateral deviation Theres more marked limitation of contralateral lateral movment Theres a radiographic evidence of bone proliferation
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HISTOLOGY FINDINGS

• A section of histology shows a fibrous
  connection
• and new bone formation.
• Intra-capsular ankylosis demonstrates irregular
  destruction of cartilage and bone
• with a sparse lymphocytic infiltration.

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SEQUELAE OF TMJ ANKYLOSIS

• Speech impairment
• Facial growth distortion
• Nutritional impairment
• Respiratory disorders
• Malocclusion
• Poor oral hygiene
• Multiple carious and impacted teeth

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MANAGEMENT

• Non surgical management
• Surgical treatment

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SURGICAL MANAGEMENT

• Aims and Objectives of surgery
• To release ankylosed mass and creation of a gap
  to mobilize the joint
• Creation of functional joint (improve patients
  oral hygiene, nutrition and good speech)
• To reconstruct the joint and restore the vertical
  height of the ramus
• To prevent re-occurrence
• To restore normal facial growth pattern
• To improve esthetic appearance of the face
  (cosmetic reason)
• Physiotherapy follow-up

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SURGICAL MANAGEMENT

• Procedures
• Condylectomy
• Gap arthroplasty
• Interpositional arthroplasty

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SURGICAL MANAGEMENT

• CONDYLECTOMY
• This procedure is usually indicated when the
  joint space is obliterated with the deposition of
  fibrous bands but, there hasnt been much
  deformity of the condylar head. Usually employed
  in cases of fibrous ankylosis.
• Pre-auricular incision is made
• Horizontal cut carried is out 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.

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SURGICAL MANAGEMENT

• GAP ARTHROPLASTY
• This procedure is employed in an extensive bony
  ankylosis.
• The section here consists of two horizontal
  osteotomy cuts
• And 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

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SURGICAL MANAGEMENT

• INTERPOSITIONAL ARTHROPLASTY
• 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

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INTERPOSITIONAL ARTHROPLASTY
SURGICAL MANAGEMENT
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SURGICAL MANAGEMENT
MATERIALS USED IN INTERPOSITIONAL ARTHROPLASTY
Autogenous Heterogenous Alloplastic
Temporalis muscles Temporalis fascia Fascia lata Cartiligenous grafts Costochondral Metatartsal Sternoclavicular Auricular graft V. Dermis chromatised submucosa of pigs bladder lyophilized bovine cartilage Metallic tantalum foil and plate, 316L stainless steel, Titanium, Gold.   Nonmetallic silastic, Teflon, acrylic, nylon, ceramic
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SURGICAL MANAGEMENT

• Advantages of this procedure (interpositional
  arthroplasty)
• Autografts, such as skin, temporalis muscle, or
  fascia lata, are presently considered the
  material of choice for interposition.
• In more recent years, a pedicled temporalis
  myofascial or temporalis fascia flap has been
  advocated in TMJ surgery to treat the TMJ
  ankylosis.
• Advantages of these flaps in TMJ reconstruction
  include
• close proximity to the TMJ without involving an
  additional surgical site,
• adequate blood supply,
• autogenous origin grafts can be used,
• and maintenance of attachment to the coronoid
  process, which provides movement of the flap
  during function, simulating physiologic action of
  the disc.

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SURGICAL MANAGEMENT
Advantages of this procedure (interpositional
arthroplasty) Post -OP
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SURGICAL MANAGEMENT

• Complications of the surgery
• Anaesthesia
• Aspiration of blood clot, tooth or foreign body
• Falling back of the tongue causing airway
  obstruction
• Intra-Operative
• Haemorrhage (damage of any superficial temporal
  vessels, transverse facial artery, etc)
• Damage to the external auditory meatus
• Damage to the Zygomatic and temp. branch of
  facial nerve
• Damage to the Glenoid fossa
• Damage to the Auriculotemporal nerve
• Damage to the Parotid gland
• Damage to the teeth
• Post Operative
• infection
• open bite
• re-occurrence of ankylosis

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FACTORS THAT PRECIPITATE RECURRENCE

• Inadequate gap created between the fragments
• 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 post-op physiotherapy
• Higher osteogenic potential and periostal
  osteogenic power may be responsible for high rate
  of recurrence in children

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CONCLUSION
Anykylosis of the TMJ is a worrisome condition of
children and adolescent which prevents normal
feeding habits, impairs speech and causes facial
deformity but if adequate surgical intervention
is carried out on time and with an intensive
follow-up, prognosis is good
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REFERENCES
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