DR SAIMA GUL

2. POST-GRADUATE TRAINEE
ORAL AND MAXILLOFACIAL SURGERY
HAYATABAD MEDICAL COMPLEX

5. TEMPOROMANDIBULAR
JOINT ANKYLOSIS

6. Temporomandibular joint
is the articulation between
squamous part of temporal
bone and the head of
mandibular condyle.

7. TMJ ARTICULATION CONSIST OF:
 Glenoid fossa
 Articular eminance
 Condyle
 External auditory meatus
 Zygomatic arch
 Sigmoid notch

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

11. Mechanism of TMJ Ankylosis
Trauma Infection
Fibrocartilage
resorbtion
C.T
formation
Heamarthrosis
Fibrous/bony
ankylosis

12. TMJ ANKYLOSIS
 Fibrous ankylosis
 fibro-osseous ankylosis
 Osseous ankylosis

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

15. DIAGNOSIS
 History
 Physical examination
 Radiographs

16. CLINICAL FEATURES

17. UNILATERAL ANKYLOSIS
EXTRA-ORAL FEATURES:
 Facial asymmetry
 Microgenia
 Short posterior facial height
 Minimal condylar movements on palpation

19. BILATERAL ANKYLOSIS
EXTRA-ORAL FEATURES:
 Bird-face deformity / Andy gump deformity
 Convex facial profile
 Retrognathic mandible
 Obtuse cervico-mental angle
 Marked decreased lower face height

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

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

25. RADIOGRAPHS
 Orthopantomogram (OPG)
 Reverse towne’s view ( PA-face )
 Lateral cephalogram
 CT- scan ( axial & coronal view)
 Magnetic resonance imaging
 CT- angiogram

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

27. ORTHOPANTOMOGRAM (OPG)

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

32. Magnetic rasonance imaging
To assess
 Meniscus position
 Fibrous ankylosis

33. Treatment

34. TEAM APPROACH
 Maxillofacial surgeon
 Orthodontist
 Anaesthetist
 Physiotherapist
 Nutritionist
 Speech therapist
 Psychologist
 Oral hygienist

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

38. AIRWAY MANAGEMENT
 Blind nasal intubation
 Fiber-optic guided oro-tracheal intubation
 Elective tracheostomy

39. Surgical Approaches To TMJ
 Preauricular incision with modifications
 Post-auricular
 Endaural incision
 Coronal incision
 Post-ramal

41. Surgical Options
Different treatment options are available
 High Condylectomy
 Gap arthroplasty
 Interpositional arthroplasty

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

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.

48. Interpositional materials
 Autogenous materials
 Heterogenous materials
 Alloplastic materials

50. Advantages
• Decreased chance
of recurrence
• Ramus height
restored
• Functionally &
histologically
restore TMJ
Disadvantages
• Increased operating
time
• Donor site
morbidity (in case
of autogenous graft)

51. Reconstruction options
 Autogenous grafts
 Alloplastic graft
 Distraction Osteogenesis (latest)

52. Graft materials
Autogenous
• Coronoid process
• Posterior border of
ramus
• Costochondral cartilage
• Sternoclavicular cartilage
• Metatarsophalangeal
graft
• Illiac crest
• Fibula
Alloplastic
• Kent –vitek total
prosthesis
• Christensen prosthesis
• Lorenz prosthesis
• Tmj
concepts/techmedica
custom made total joint
prosthesis

53. COSTOCHONDRAL GRAFT

54. Techmedica total joint
prosthesis
Christensen prosthesis

55. Kent-vitek prosthesis Techmedica /tmj concepts Lorenz prosthesis

56. Distraction osteogenesis

60. Distraction osteogenesis

62. CONSOLODATION PERIOD , FACIAL PROFILE

63. 3 cm of transport distraction being done

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.

68. TONGUE BLADES EXERCISE

69. FERGOSSON MOUTH GAG

70. PASSIVE MOUTH EXERCISER

72. PRE-OP MOUTH OPENING

74. INTERPOSITIONAL ARTHROPLASTY WITH ARTICULATING DISK

75. POST-OP MOUTH OPENING

76. PRE-OP MOUTH OPENING

77. INTERPOSITIONAL ARTHROPLASTY WITH TEMPORALIS FASCIA

78. POST-OP MOUTH OPENING

79. COMPLICATIONS

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

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).