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CASE PRESENTATION

GENERAL
INFORMATION


Patient named Madhavi of
age 7 yrs hailing from
Aravapalem village came
to the department with the
chief complaint of inability
to open the mouth .

History of present illness-

No history of ear infections.


The patients attenders elicits History of delivery in a public
bus where the child had a fall to the floor of bus, the point
of impact is not known. There was a partial mouth opening
at birth which gradually decreased to the present condition.

Medical history-

No relevant personal dental and family history


On her 4th day after birth Underwent treatment to
right eye after she had trauma due to accidental
hit of her grandmother’s nail while bathing,
during the treatment period there was infection
and resulted in loss of vision within 7 days.

General examination-


Patient is poorly built and
malnourished.
Pallor
Vitals – no significant
findings detected
BP-120/80 mm of Hg
Temperature – afebrile
RR-20 times/min
PR-84 times/min

Systemic examinationno relevant abnormality detected.

Local examinationExtra oral- On InspectionFacial asymmetry detected with soft tissue
fullness on left side.
Chin deviated to left-1cm

Mouth opening restricted-1mm
No lateral and antero-posterior extrusive
movements of lower jaw.
Chin receeded with hypoplastic mandible.
Condylar movements severly restricted.
Thyro- mental angle reduced.
Shortening of ramus is observed on the left
side.


Lips incompetent

Extra oral examinationPalpationOn palpation the inspectory finding are
confirmed.

Prominent gonial angle on left side.
Steep mandibular angle on left.
Short body of mandible on the left side.
Foreshortening of Ramus on left side.
Condyle movement is severely
restricted.
On clenching masseter muscle is tensed


Lower border of mandible is concave on
left side with Accentuated antegonial
notch on both sides with more severity on
left.

Intra oral examinationOn inspection anterior open bite
present.

Class – 2 malocclusion

Midline shift-7mm
Malpositioning of teeth.
Tongue thrust is positive.

Right side scissor bite and left side
cross bite.
Poor oral hygiene.

Mild difficulty in deglutition.


Overjet-9mm

Provisional clinical diagnosis-


Unilateral left TMJ ankylosis.

Investigations –
Radiological-

CT Scan with 3-D reconstruction.
Surgical profile


O.P.G.

O.P.G


C.T Scan-


Comparision of left and right


Radiological diagnosisUnilateral left bony ankylosis of TMJ.

Treatment plan-


Aggressive resection of left condyle and coronoid with
interpositional arthroplasty by temporalis muscle or
costochondral graft.
Followed by aggressive physiotherapy and muscle
excercises .

DEFINITIONS
True ankylosis

Pseudo-ankylosis
Mechanical interference - joint hypomobility
and the joint is normal.
Fibrous ankylosis, coronoid hyperplasia or
fusion of coronoid process with the tuberosity of
maxilla or zygoma are examples of pseudoankylosis


Intra-capsular condition - fusion of the bony
surfaces of the joint - the condyle and glenoid fossa.

CLASSIFICATIONS
KAZANJIAN (1938)

b. False ankylosis


a. True ankylosis

CLASSIFICATIONS









Fibrous
Fibro-osseous
Osseous
Cartilaginous

Pseudo-ankylosis
False ankylosis.


ROWE’S MODIFICATION (1986)

True ankylosis:

Sawhney’s classification (1986):

CLASSIFICATIONS
TYPE-2
Deformed
condylar head
with lost
function,decreased joint space
and dense
fibrous adhesion
.TYPE-3
Bony block from
asc ramus to
zygomatic arch,
condyle
deformed .

Ant or post bony
fusion of
misshaped
condyle with
articular
surface,lateral
lipping .

TYPE -1

TYPE-4

Totally deformed
anatomy, bony
mass,with
complete fusion

CLASSIFICATIONS
Based on etiology:
Traumatic
Congenital (Forcep delivery)
Childhood trauma
Adulthood trauma

Can also be
i. Osseous
ii. Fibro-osseous
iii. Fibrous
iv. Cartilaginous or osteocartilaginous






Systemic inflammatory&rheumatological disease.
(10%)
Rheumatoid arthritis (30-70%)



Psoriatic arthritis (1-2%)



Ankylosis spondylitis (1-50%)

Others


Scleroderma



TMJ surgeries



Irradiation



Idiopathic (50%)



Osteochondromas


•

Classification on CT findings-Sashi aggarwal(1989)
 Type

II-joint architecture completely
disrupted
large mass of bone
midline shifted to the affected side
3.5 cm in maximum thickness


 Type

I-condyle could be identified
mild to moderate bone formation
lateral part of articular fossa
2.5 cm in max thickness

CLASSIFICATIONS
Modified classification based on CT-scan: El-Hakim, S A

Metwalli (2003)
Class I- includes uni &bil fibrous ankylosis



Class II-uni or bil bony fusion



Class III- distance b/n maxillary artery & the medial pole
of the mandible is less on the ankylosed side



Class IV-ankylosed mass appeared fused to the base of
skull




CLASSIFICATIONS
Topazian three-stage classification

I, ankylotic bone limited to the condylar
process;

 stage

II, ankylotic bone extending to the sigmoid
notch;



stage III, ankylotic bone extending to the
coronoid process.


 stage

ETIOLOGICAL FACTORS
HYPO-MOBILITY



TRISMUS
Odontogenic
Infection
Trauma
Tumours
Psychologic
Pharmacologic
Neurologic

 PSEUDOANKYLOSIS

1.DEPRESSED ZM ARCH #

3.ADHESIONS OF CORONOID PROCESS
4.HYPERTROPHY OF CORONOID PROCESS

5.FIBROSIS OF TEMPORALIS MUSCLE
6.MYOSITIS OSSIFICANS
7.SCAR CONTRACTURE
8.TUMOUR OF CONDYLE OR CORONOID


2.FRACTURE DISLOCATION OF CONDYLE

TRUE ANKYLOSIS


TRAUMA(31—98%)
1.Intracapsular # in child

3.Intracapsular fibrosis
4.Obstetric trauma(Foreceps delivery)


INFECTION(10—30%)
1.Otitis media
2.Suppurative arthritis


2.Medial displaced condylar # adults



INFLAMMATION(10%)
1.Rheumatoid arthritis

2.Still’s disease(juvenile idiopathic arthritis)
4.Psoriatic arthritis


IATROGENIC
Postoperative complication of
1.TMJ surgery

2.Orthognathic surgery


3.Ankylosing spondylitis

ETIOLOGIES
Organisms may reach the joint by instrumentation
Lacerated wound.

2.

Through bloodstream

3.

Direct extension from infection of neighboring
structures.

4.


1.

Blunt trauma.

Staphylococci, streptococci and occasionally gonococci.

TOPAZIAN LISTS THREE MECHANISMS

1.

Primary Otitis media causing secondary joint

2.

Suppurative arthritis of TMJ involving the middle
ear secondarily

3.

Suppurative arthritis of the joint draining into the
cartilaginous canal.


involvement.

Infection from mastoiditis in 3 ways
1.

2.


3.

Direct extension
Thrombophlebitis
Hematogenous dissemination

Dried skull > 10 years of age - tiny opening or perforation
in the central part of the tympanic plate - incomplete
ossification.
Infection can spread through
1.
Opened sutures
2.
Incomplete ossification
3.
Delayed ossification


PATHOGENESIS

ETIO-PATHOGENESIS
Microtrauma
Local Infections

Systemic Infections

Hemarthrosis
Drop in O2 Tension
& PH

Promotes
Osteosynthesis
Ankylotic Mass


Trauma

DIAGNOSIS
History, Clinical, Radiographic examination.
Norman Rowe
2. Inability to open mouth or marked limitation.
3. Slight motion of the condyle of the non-involved side.

4. Slight motion from springing of the fibro-osseous tissue on the
involved side;
in the bilateral case, movement may be impossible.


1. H/O injury to, or infection of the jaws.

5. Asymmetry of the face

6. Flattening of face
7. Shift of symphysis

9. Shortness of vertical and horizontal ramus of the
mandible.
10. Deep antegonial notch on the involved side.
11. Decreased or almost absent joint space


8. Normal occlusion of the teeth on uninvolved
side

CLINICAL MANIFESTATIONS
Vary according to
Severity of onset

2.

Time of onset

3.

Duration

Early-below 15 years, severe facial deformity and loss of
function
Late– after 15 yrs.. Facial deformity nil, function loss


1.

UNILATERAL ANKYLOSIS
 Obvious

deformity

 Chin

to affected side

receded with hypoplastic

mandible on affected side
 Lower

border - concavity

 Cross

bite

 Class

II

 Condylar

movements absent


 Deviation

BILATERAL ANKYLOSIS
 MIO

decreases

- micro

but symmetrical
 Bird

face deformity

 Neck

chin angle - absent

 Multiple
 Less

carious tooth

than 5 mm

 Upper

incisors often protrusive


 Mandible


RADIOLOGY

RADIOGRAPHS
OPG



Lateral Tomograms



PA Mandible



Trans cranial TMJ



Contrast enhanced CT scan.



MRI



3-D reconstruction




PANORAMIC VIEWS
Joint deformity
Loss of the joint space
Abnormal bone formation in and around the joint,

These details are clearly apparent - CORONAL CT - illustrate

whether the ankylotic mass is fibrous or bony.

POST-CONTRAST CT demonstrate
the relation to surrounding vital structures, especially the maxillary
artery.
These findings ASSIST in
Better surgical planning and therefore reduced operating time
and surgical complications.


Do not reveal the nature and the extent of the pathology, in particular the medial
and lateral extension of the ankylosed bony mass, and its relation to surrounding
vital structures.

ANESTHETIC CONSIDERATIONS


Limited protrusion, diminished lateral excursion, as well as
trismus.
Failure to properly manage the airway - life threatening



Conventional tracheal intubation cannot be performed if the
MIO < 25mm




TECHNIQUES


If the mouth opens less than 25 mm,
 Transoral fibreoptic bronchoscopy-assisted intubation,
 Transnasal fibreoptic bronchoscopy-assisted intubation,
 Tracheostomy, or
 Blind nasal intubation should be performed under
sedation or using general inhalation anaesthesia with the
patient breathing spontaneously



Incidence of laryngospasm - 8.6 : 1000 in adults and
27.6 : 1000 in children



Topical lidocaine, succinylcholine, and positive pressure



Bilateral superior laryngeal nerve block -severe repeated
postoperative laryngospasm


ventilation - standard management of laryngospasm

ANKYLOSIS IN CHILDREN
REASONS:
1. Articulating surfaces highly vascular
3. Vascular articulating disc
4. Thick and stout condylar neck
5. Hemoarthrosis and CO2 tension

6. Greater osteoblastic activity


2. Flat and broad glenoid fossa

SURGICAL TREATMENT IN CHILDREN
Two objectives
1. To improve mandibular function

1. Type 1&2 high condylar shave. 3-4mm of gap. Disc to be
mobilized
2. Destroyed condyle to be replaced by grafts


2. Normal growth and development

SURGICAL ACCESS TO TMJ


Potential problems
Facial nerve
Terminal branches of ECA


Serious morbidity from facial nerve overshadows the mechanical improvements in
joint function


Access to temporomandibular joint - important
for surgical success.

APPROACHES
• Preauricular
• Postauricular

• Rhytidectomal
• Submandibular
• Intraoral


• Endaural

OBJECTIVES

GOALS

Maximize exposure

prevent disease progression



Facial nerve

restore mandibular form



Major vessels

function



Parotid gland

diminish patient suffering



Maximize use of skin creases

disability


o


PREPARATION FOR SURGERY…..

PREAURICULAR APPROACH (BLAIR)
MODIFICATION OF THE BLAIR CURVILINEAR OR INVERTED- L
INCISION


ENDAURAL APPROACH


ADVANTAGES
Excellent access to the lateral and posterior
aspects of the joint
 Esthetically acceptable
 Scar hidden



Disadvantage
 potential for perichondritis

AL-KAYAT & BRAMLEY (1979)
MODIFIED PRE-AURICULAR APPROACH




Following advantages,











Minimal bleeding and less sensory loss.
Facial planes arc easily identified.
Excellent visibility.
Potential complications of muscle herniation and
fibrosis are avoided.
Remarkably little post-operative discomfort or
swelling.
Good cosmetic result is achieved except in the very
bald.
Technique is easily teachable and speedily executed.

Others



POSTAURICULAR APPROACH
(ALEXANDER & JAMES-1975)


ADVANTAGES
Excellent exposure of the entire joint
 Ability to camouflage the scar in patients –
keloids.


should not be used – joint infection
chronic otitis externa


Disadvantage
 Auricular stenosis

SUBMANDIBULAR APPROACH
(RISDON-1934)


RHYTIDECTOMY
Face-Lift approach
 Variant of the retromandibular approach.
 Difference - placement of the incision.
 Provide greater exposure to the superior joint
cavity
 However, it requires additional time for closure.



TREATMENT OPTIONS
1. Gap arthroplasty

3. Joint reconstruction


2. Interpositional arthroplasty

TREATMENT DECISION MAKING


GAP ARTHROPLASTY


ADVANTAGES
 Simplicity
 Short

operating time

 Pseudo-articulation
 Short

ramus height
 Failure to remove all bony disease
 Development of open bite {bilat cases}
 Suboptimal range of motion
 Recurrent ankylosis (60%)


DISADVANTAGEs

INTERPOSITIONAL ARTHROPLASTY

TEMPORALIS FASCIA FLAP


ADVANTAGES
Simplicity
 Short operating time



DISADVANTAGES
 Donor site morbidity if auto….
 Risk of foregin body reaction if allop….
 Failure to remove all the bony pathology

KABAN’S PROTOCOL (1990)
Aggressive resection

2.

Ipsilateral coronoidectomy

3.

Contralateral cronoidectomy (if necessary)

4.

Lining of TMJ with temporalis fascia or cartilage

5.

Reconstruction of ramus using costochondral
graft

6.

Rigid fixation

7.

Early immobilization and aggressive
physiotherapy


1.

SALIN’S PROTOCOLThe ankylotic mass itself is not resected
 Bone is not removed to create a gap
 Functional pseudoarthrosis is created between
the normal bone surface.



OTHER TECHNIQUES PROPOSED








Nitzan et al.- in type 3 ankylosis involving TMJ
preservation of existing articular elements to form a
joint after selective elimination of the bony bridge,
JOMS-1998:56:1133-8
Chossegross et.al- used full thickness skin graft from
groin region as inter-positional material and acquired
92% success with 3years follow-up, IJOMS1999:28:330-4
Gunaseelan R. condylar resection in extensive
ankylosis in adults followed by usage of resected
segment as autograft. IJOMS-1997:26:405-7
Herbosa and Rotskoff –used composite temporalis
pedicle flap as an interpositional graft- 18 months of
follow-up showed significant improvement in
mandibular range of motion due to compensatory
rotational movement.-JOMS-1990:48:1049-1056.

CONTD..,



Balaji evaluated the long termoutcome of
temporalis flap with sub-condylar anchorage in
management of re-ankylosis.IJOMS-2003:32:480485.

RECONSTRUCTION


AUTOGENOUS AND ALLOPLASTIC

GOALS FOR TMJ RECONSTRUCTION
of joint and muscle pain.

 Restoration

of normal joint function

 Restoration

normal posterior vertical dimensions and

length.
 Stable

skeletal occlusal relationship

 Maintenance
 Lifetime

of facial symmetry

maintenance of restored function, comfort
and esthetics


 Elimination

AUTOGENOUS TMJ REPLACEMENT


1909 – Bardenheur - replaced condyle - 4th metatarsal



1920 - Gillies used costochondral graft
Costochondral graft

Metatarsal graft
Sternoclavicular graft
Calvarial bone graft

AUTOGENOUS DISK REPLACEMENT
Dermis graft
Auricular graft

Temporalis myofacial flap


DONOR SITE ALTERNATIVES-



Purpose of using costochondral grafts for reconstruction
of TMJ ankylosis is twofold:

ankylosis,
2) To restore the joint’s form and function.


1) To ensure a wide gap arthroplasty for release of the

ADVANTAGES


Biologic acceptability and remodeling by
oppositional growth, especially in children

DISVANTAGES
 Increased operating time
 Additional surgical site

COMPLICATIONS
Donor site morbidity,
such as
 Pneumothorax & pleuritic pain
 Potential overgrowth of the graft
 Suboptimal postoperative range of motion



intra-articular adhesions,

prevent soft tissue contraction
stretch maturing fibrous tissue,
 redevelop normal
muscle function.


Early movement will prevent--


ALLOPLASTIC JOINT REPLACEMENTS

HISTORY
John Murray treated ankylosis - wood block

 1890–

Gluck - ivory prosthesis

 1933

– Risdon – gold foil

 1947

– Goodsell - titanium foil

 Total

joint - Kent-Vitek prosthesis

 Christensen



– 1964 - lined glenoid fossa —vitallium

Chase – 1995 - chromium cobalt head


 1840–

INDICATIONS


Ankylosed, degenerated or resorbed joints with severe



Failed autogenous bone grafts



Destruction of autogenous bone due to preexisting

foreign body reaction.


Recurrent ankylosis.



Severe polyarticular inflammatory joint disease of TMJs


anatomic discrepancies

RELATIVE CONTRAINDICATIONS
Insufficient patient age



Lack of understanding of the patient



Uncontrolled systemic disease



Allergic to materials used in devices



Active infection at implantation site.




ADVANTAGES
Physical therapy can begin immediately
 No need for second donor site
 Reduced surgical time
 Alloplasts – mimic normal anatomic contours, better adapted to
the bony surfaces.
 Stable occlusion post-operatively
 Decreased hospital stay
 Opportunity to manipulate prosthesis design to discourage
heterotrophic bone formation



DISADVANTAGES
Cost of prosthesis



Material wear and failure



Long term stability



Inability to follow patients growth



Potential for severe giant cell reactions




ALLOPLASTIC CONDYLAR
PROSTHESIS

KENT-VITEK TOTAL JOINT PROSTHESIS

CHRISTENSEN SYSTEM

Metal to metal

Type1 & 2

COMPLICATIONS
Foreign-body reaction to some materials
 Erosion of metal condylar prosthesis into the
glenoid fossa
 Suboptimal postoperative range of motion
 Loosening of screws and loss of stability



FAILURES


DIAGNOSIS OF FAILED ALLOPLASTIC IMPLANTS
 Swelling

with or without visual confirmation and
ed tightness in and around joints
ed hearing or fullness in the ears without
abnormal otologic findings



ed pain in the joint with function with or without
headaches in temple area



ing ability to masticate food



ing range of motion



ing sound in the joint

 Posterior

open bite




ON THE WORK OF GHELMAN - RADIOGRAPH OF ANY
ALLOPLASTIC TMJ REPLACEMENT:

1. The position of the components,

3. The presence of metal fractures,
4. Areas of ectopic bone formation.
5. Metal fragments in and/or around the joint.


2. The position of the fixation screws.

6. Host bone osteolysis around major components and/or fixation
screws.
7. Infection.

COMPLICATIONS
1.

Bleeding
1.
2.
3.

3.
4.
5.
6.
7.

Facial Neuropraxia
Wound Infection
Venous thrombosis
Frey’s syndrome
Otitis externa and Otalgia
Facial scarring


2.

Edge of temporalis muscle.
Maxillary and mandibular vessels.
Pterygoid venous plexus

COMPLICATIONS

Prevention of re-ankylosis




8. Reankylosis

10-15% of cases

Within 6 months

Especially in children of 6-8yrs of age

Physio therapy
The post-operative follow-ups should be weekly for the first 1
month, followed by monthly for the next 5 months. Successive
follow-up recalls should be made till 2 years post op to ensure
that the patient does not develop a re-ankylosed joint.

POST-OP REHABILITATIONDISTRACTION OSTEOGENESIS- of body of
mandible- one stage vs two stage2011 American
Association of Oral and Maxillofacial Surgeons
 J Oral Maxillofac Surg 69:e565-e572, 2011




CONCLUSION

REFERENCES
*A TEXTBOOK & COLOUR ATLAS OF TMJ DISEASES,
DISORDER, SURGERY - J. E. DeBURGH NORMAN
*MAXILLOFACIAL TRAUMA – ROBERT H. MATHOG
*SURGERY OF THE TMJ – DAVID ALEXANDER KEITH

DIAGNOSIS, MANAGEMENT - WELDEN E. BELL
*ORAL AND MAXILOFACIAL INFECTIONS – TOPAZIAN
*TEXT BOOK OF ORAL MEDICINE – BURKETT.
*TEMPOROMANDIBULAR DISORDERS – KAPLAN

*MANAGEMENT OF TMJ DISORDERS AND OCLUSION –
JEFFREY OKESON
*MAXILLOFACIAL SURGERY – PETER WARDBOOTH


*TEMPOROMANDIBUALR DISORDERS CLASSIFICATION,

REFERENCES
*A Protocol for Management Of TMJ Ankylosis
Leonard B Kaban, David H Perrott, Keith Fisher JOMS; 48; 1990:
1145-51

*New Perspectives In The Management Of Cranio-Mandibular
*Bone Ankylosis of the TMJ. A CT study Sashi Aggarwal, Sima
Mukhopadhyaya, Manorama berry, OOO; 1990; 69: 128-32
*Imaging of TMJ; A New Radiographic Classification. IE El-Hakim,
S A Metwalli Dentomaxillofacial Radiology 2002; 31; 19-23.
*A Clinical Study on TMJ Ankylosis - Behcet Erol, Rezzzan
Tanrikulu, Belgin Gorgun J Craniomaxillafacial Surg; 2006; 34


Ankylosis. P C Salins, IJOMS, 2000; 29; 337-40

REFERENCES
*The Effect Of Intra-Articular Bone Fragments In Genesis of
TMJ Ankylosis - H Miyomoto, K Kurith, N Ogi,
*Development of human TMJ - David A Keith
BJOMS 1982; 20; 217-20
*TMJ Ankylosis - Henk Tideman
ADJ; 1987; 32(3); 171-77
*TMJ Ankylosis following mastoiditis - Thomas H Faerber,
Robert Ennis
JOMS, 1990; 866-70


IJOMS 2000; 29; 290-95

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