Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Kaban protocol tmj ankylosis treatment orignal 1990

5,527 views

Published on

Kaban protocol tmj ankylosis treatment orignal 1990

Published in: Health & Medicine
  • Login to see the comments

Kaban protocol tmj ankylosis treatment orignal 1990

  1. 1. A PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS LEONARD B. KABAN ET AL J ORAL MAXILLOFAC SURG 48:1145-1151, 1990
  2. 2. INTRODUCTION  Mandibular hypomobility results from a variety of disorders affecting the temporomandibular joint (TMJ) and surrounding structures.  It may be classified by a combination of: • Location (intra- or extra- articular). • Type of tissue involved (bony, fibrous, or fibro-osseous). • Extent of fusion (complete, incomplete).
  3. 3. INTRODUCTION  Ankylosis is most commonly associated to: • Trauma (31% to 98% of cases). • Local or systemic infection (10% to 49%). • Systemic disease (1O%).
  4. 4. INTRODUCTION  TRAUMA  Intra-articular hematoma + scarring and excessive bone formation.  LOCAL  Hematogenous spread including tuberculosis, gonorrhea, and scarlet fever.  SYSTEMIC  Ankylosing spondylitis, rheumatoid arthritis, and psoriasis.
  5. 5. OPERATIVE TECHNIQUE The TMJ approach Through a curvilinear preauricular incision.
  6. 6. AGGRESSIVE EXCISION  After exposure and identification of the site of ankylosis  Aggressive excision of the fibrous or bony mass was carried out.
  7. 7. CORONOIDECTOMY Coronoidectomy, and dissection and stripping of muscle (temporalis, masseter, and medial pterygoid) Ipsilateral side.  Excision of the ankylotic tissue and coronoidectomy usually resulted in loss of one third of the ramus height.
  8. 8. CONTRALATERAL CORONOIDECTOMY Following excision of the ankylotic mass and coronoidectomy If the MIO was less than 35 mm (without the use of force), a contralateral coronoidectomy was performed via an intraoral approach.  After optimal interincisal opening was achieved, the joint was reconstructed.
  9. 9. LINING OF GLENOID FOSSA If an intact disc During the resection of the mass, it was maintained to line the glenoid fossa.  In other cases, the TMJ was lined with a finger-shaped temporalis fascia flap rotated over the arch into the joint.  The thickness of the flap was dictated by the joint space requirement. A minimum of 4 mm is necessary.
  10. 10. MMF Following resection of the fibrous mass + coronoidectomy + lining of the joint. Arch bars.  Maxillomandibular fixation (MMF) using a prefabricated occlusal splint to establish the occlusion.  A 2mm posterior open bite was created to compensate for remodeling of the costochondral graft.
  11. 11. RECONSTRUCTION  Reconstruction of the condyle was achieved with a 6-cm costochondral graft.  The cartilage was contoured to be 5-mm thick and round in shape.  The lateral ramus was exposed via a submandibular incision and both the ramus and rib were trimmed and contoured to produce a good bony interface.
  12. 12. RECONSTRUCTION  The top of the graft was then placed against the temporalis flap and rigidly secured to the mandible with two or three 2.7-mm tapped bone screws.  A drain was placed, the incisions were closed, and a pressure dressing was applied.
  13. 13. DIET & PHYSIOTHERAPY  After release of MMF, patients were started on a soft diet and jaw- opening exercises. Active hinge opening, lateral excursions and manual finger stretching.  During the next 3 to 4 weeks, the diet was advanced to a solid consistency.
  14. 14. DISCUSSION  Many operative techniques have been described in the literature, but results have been variable and often less than satisfactory. 1. Gap arthroplasty. 2. Interpositional arthroplasty. 3. Joint reconstruction with autogenous or alloplastic materials.
  15. 15. GAP ARTHROPLASTY  When performing a gap arthroplasty, the surgeon bypasses the intra- articular ankylosis and creates a gap distal to the fused TMJ.
  16. 16. GAP ARTHROPLASTY  Advantages 1. Simplicity and short operating time.  Disadvantages 1. Creation of a pseudo-articulation and a short ramus. 2. Failure to remove all the bony pathology. 3. Increased risk of reankylosis.  MIO greater than 30 mm was reported in only 5 of 20 (25%) patients by Topaziann and 11 of 17 (65%) by Rajgopal et al.
  17. 17. INTERPOSITIONAL ARTHROPLASTY  In the case of an interpositional arthroplasty, autogenous or alloplastic materials are placed in the ostectomy site to prevent recurrent ankylosis. Acrylic resin, skin, and dermis have all been used for this purpose.  Advantages 1. Similar as GAP ARTHROPLASTY.
  18. 18. INTERPOSITIONAL ARTHROPLASTY  Disadvantages 1. Donor site morbidity if autogenous materials. 2. Risk of foreign-body reaction if alloplastic materials. 3. Failure to remove all the bony pathology.  MIO of greater than 35 mm was reported in 2 of 70 (2.8%) patients by Sawhney,  32 of 76 (42%) by Popescu et al and 12 of 17 (70%) patients by Hili.
  19. 19. JOINT RECONSTRUCTION  TMJ ankylosis also has been treated by excision and total joint reconstruction with alloplastic or autogenous materials.  Advantages 1. Lack of a donor site. 2. Immediate return to function.
  20. 20. JOINT RECONSTRUCTION  Complications 1. Foreign-body reaction to some materials. 2. Erosion of metal condylar prothesis into the glenoid fossa. 3. Suboptimal postoperative range of motion. 4. Loosening of the screws and loss of stability.  Kent et al reported an increased MIO in 44 of 76 (58%) patients.
  21. 21. JOINT RECONSTRUCTION  For autogenous materials, eg, costochondral rib grafts, sternoclavicular joints, iliac crest grafts.  Advantages 1. Biologic acceptability and remodeling by appositional growth, especially in children.
  22. 22. JOINT RECONSTRUCTION  Complications 1. Donor site morbidity, such as pneumothorax and pleuritic pain, potential overgrowth of the graft, and suboptimal postoperative range of motion.  Lindquist et al reported a mean MIO of 30.5 mm in a series of 27 cases  Munro et al reported an MIO of greater than 35 mm in 3 of 17 (18%) cases.
  23. 23. CONCLUSION  Regardless of the technique used, a mean post- operative MIO greater than 35 mm is rarely achieved.  For this study, they have defined normal function as an MIO greater than 35 mm, the ability to make lateral excursions, minimal to no pain during function and resumption of a normal diet.
  24. 24. CONCLUSION  The approach described in this study includes seven steps: 1. Aggressive resection of the bony or fibrous ankylotic segment. 2. Ipsilateral coronoidectomy. 3. Contralateral intraoral coronoidectomy when necessary. 4. Consists of creating a new joint lining. 5. Reconstruction of the ramus with a costochondral graft. 6. Securing it with rigid fixation. 7. Consists of early mobilization and aggressive physiotherapy.
  25. 25. CONCLUSION  1 pediatric patient did develop a contour abnormality and required revision for cosmetic reasons  On exploration the graft had developed lateral overgrowth at the costochondral junction.  The results of this study indicate that this protocol is effective for treatment of TMJ ankylosis.
  26. 26. THANK YOU

×