9. TMJ ANKYLOSIS
TMJ Ankylosis is the fusion of the
Mandibular condyle with the glenoid
fossa , oblitering the normal
articulation and immobilizing the
mandible.
10. Causes of TMJ Ankylosis
TRAUMA
• Condylar
fracture
• Heamarthrosis
• Obstetric
trauma
INFLAMATION
• Rheumatoid
arthritis
• Ankylosing
spodylitis
• Still’s disease
• Psoriatic
arthritis
SURGICAL
• Post-op
complication of
TMJ or
orthognathic
surgery
INFEC
INFECTION
•Otitis media
•Supurative
arthritis
•Parotitis
•mastoiditis
13. Al-Hakim , SA Metwali 2003
CLASS I: Includes unilateral & bilatral fibrous ankylosis
CLASS II: Includes unilateral or bilateral bony anlylosis
CLASS III :Distance between medial pole of condyle and
maxillary artery is decreased
CLASS VI: Ankylosed mass appeared fused to base of
skull
14. Topazian’s STAGING
Stage I : Ankylotic mass limited
to condylar process
Stage II: Ankylotic mass extending
to the sigmoid notch
Stage III: Ankylosis extending to
coronoid process
21. INTRA-ORAL FEATURES:
Midline shift towards effected side
Class II malocclusion
Cross-bite (unilateral/ bilateral)
Limited mouth opening
Neglected oral hygiene with carries & periodontal
problems
22.
23.
24. ASSOCIATED PROBLEMS
Interferes with the mastication of food and with
nutrition
Interference with speech
Psychologic problems
Prevents oral hygiene and prophylactic care
Obstructive sleep apnea due to narrowing of oro-
pharyngeal airway
26. RADIOGRAPHIC FEATURES:
Narrowing of joint space in fibrous ankylosis
Total joint space obliteration in bony ankylosis
Short ramal height
Prominent antegonial notch
Crowding in lower teeth
Elongated coronoid process of mandible
28. Lateral Cephalogram
To assess
Narrowing of airway
Antero-posterior extension
Elongation of coronoid
Shortened PFH
Steep mandibular plane
Retrognathia
Retrogenia
29. CT-scan / 3D CT-scan
To assess:
Relationship with the base of skull and important
structures like
Pterygoid plates
Carotid canal
Jugular foramen
Foramen spinosum
35. GOALS OF SURGICAL TREATMENT
Restore mouth opening
Restore joint function
Allow for condylar growth (children)
Correct facial profile
Relieve upper airway obstruction
36. Treatment protocol
1. Early & aggressive surgical resection of
the ankylotic mass
2. Coronoidectomy + myotomy on the
affected side.
3. If still not created enough opening,
contralateral coronoidectomy is done.
4. Lining the joint with temporalis fascia or
cartilage.
37. Continue…….
6. Reconstruction of ramal height.
7 Early post-operative aggressive physiotherapy
8 Orthodontic treatment.
9 Regular long term follow-up
10 Orthognathic surgery
42. High Condylectomy
‘High condylectomy is the resection of only upper part
of condylar head.’
It is indicated in cases of fibrous ankylosis where the
articular space has not been completely eliminated.
43. Gap arthroplasty
An osteoarthrotomy is performed to remove a slice of
bone about 1.5 – 2 cm in width , which is known as ‘
gap arthroplasty ’
INDICATION:
Bony ankylosis
44.
45. The mouth is forced open with the help of a mouth
gag to check the mouth opening -a gap of 1.5 - 2 cm is
created & not interposed with any material.
Post-op, this gap is maintained by active
physiotherapy to prevent re-ankylosis.
46. Advantages
• Simple procedure
• Short operating
time
Disadvantages
• Creating a pseudo-
articulation
• Shortening of
ramus
• High recurrence
rate.
47. Interpositional arthroplasty
It involves the creation of gap but in addition inserting
a barrier between two bony cut ends to minimize
chances of re-ankylosis and to maintain the vertical
height of ramus.
64. Latest advancement in
management
Navigation-aided resection of ankyloting mass
Holmium-YAG laser with the help of arthroscope for
fibrous ankylosis
Tissue engineered TMJ reconstruction
65. Post-op treatment
After surgery, a pressure dressing is applied with a
bandage.
A drain is placed.
The patient is kept on steroids + antibiotic therapy for
7 to 10 days.
After 24 hours the dressing is changed .
Active physiotherapy start from 2nd post-op day.
Remove skin stitches on 5th- 7th post op day.
66. Post-op physiotherapy
Physiotherapy is as important as the surgery itself.
Post- operatively for minimum for 6 months.
Pressure with finger or simple finger exercises to
gently force the mouth open initially with tongue
blades / acrylic screw / jaw exerciser.
67. continue…...
A mouth gag can be used for forceful mouth
opening at a later stage.
During physiotherapy, medications can be given to
relieve pain and enable movement.
Heat application to the joint region prior to
exercise permits easy movement by relieving
muscle spasm.
80. Per-op complications
Difficult intubation
Difficult tracheostomy due to smaller trachea
Hemorrhage
Damage to external auditory meatus.
Damage to nerves (zygomatic & temporal branch of facial
nerve, auriculotemporal nerve)
Damage to glenoid fossa and thus perforation into middle
cranial fossa.
Damage to parotid gland.
Damage to the teeth during opening of the jaws with
mouth gag and extubation.
81. Post-op complications
Extra-oral scar
Infection
Open bite
Anaesthesia /paresthesia due to nerve damage
Weakness of muscles of facial expressions
Frey’s syndrome
External auditory meatus stenosis
Recurrence of ankylosis
82.
83.
84.
85. Follow -up
Asses airway
Facial profile
Measure mouth opening
Occlusion
Oral hygiene status
Nutritional status
Psychologic behaviour
Need for orthodontic treatment/Orthognathic surgery
Any complication and its management
Keep patient’s record
86. References :
Peter ward booth, stephen A.schendel ,jarg-erich hauseman
.Maxillofacial surgery vol II second edition.
Neelima anil malik.textbook of oral and maxillofacia surgery 3rd
edition.
Miloro M, Ghali GE, Larsen P, Waite P. Petersons principles of oral and
maxillofacial surgery,volume II. Third edition.
Muralee Mohan C. , B. Rajendra Prasad , Smitha Bhat & Shyam S. Bhat.
reconstruction of condyle following surgicalcorrection of
temporomandibular joint ankylosis: current concepts and
considerations for the future. nujhs2014:4(2).
Dr Neetu Dabla,1 Dr P Narayana Prasad,2 Dr Arjun Vedvyas,3 Dr Richa
Aggarwal. Treatment of Facial Asymmetry and Temporomandibular
Joint.Ankylosis by Distraction Osteogenesis: A Case
Report.OJON2013:3(2).