ORAL MAXILLOFACIAL SURGERY

1. ANKYLOSIS OFANKYLOSIS OF
TEMPOROMANDIBULARTEMPOROMANDIBULAR
JOINTJOINT
BY
DR NINGOMBAM
ROBINSON SINGH

2. • Ankylosis is a greek word meaning “Stiff
joint” and denotes hypomobility or no
mobility. Inability to open the mouth
beyond 5 mm of interincisal opening due
to fusion of head of the condyle with the
articulating surface of the glenoid fossa is
termed as ankylosis of TMJ.

3. • Definition:- Ankylosis refers to the
partial or complete inability to open
the mouth which results in functional
and growth deformation of the
mandible.

4. ANATOMY OF TMJANATOMY OF TMJ
TMJ is highly specialised ,diarthroidal
non weight bearing synovial joint of
condylar variety
ARTICULAR SURFACES:-
upper surface :-
a) articular eminence
b) anterior part of the mandibular fossa
lower surface:- Head of the mandible

5. BONY COMPONENT:-
º consist of glenoid fossa of the temporal
bone & mandibular condyle.
º condyle is roughly elliptical in cross
section with mediolateral width being
two times the anteroposterior width.

6. º the glenoid fossa is a smooth depression in
the temporal bone which is thinnest in its
deepest part which separates the joint
from the middle cranial fossa.
º articular surface is covered by
fibrocartilage.

8. SOFT TISSUE COMPONENT:-
1) Intraarticular disc or meniscus
2)Synovial membrane
3) Lateral pterygoid muscle
4)Capsule of joint
5) Ligaments-
a) temporomandibular (lateral) ligament
b) sphenomandibular ligament
c) stylomandibular ligament
d) anterior malleolar ligament

10. NERVE SUPPLY:-
1) articulotemporal nerve
2) masseteric branch of mandibular nerve
BLLOD SUPPLY:-
1) superficial temporal branch of external
carotid artery
2) middle meningeal artery

11. APPLIED PHYSIOLOGYAPPLIED PHYSIOLOGY
Movement produced by muscle of
mastication in the upper joint cavity gliding
movements and in the lower joint cavity
hinge movements take place.
movements are:-
- Protrusive -Retraction
-Depression -Elevation
-Lateral or side to side movements

12. CLASSIFICATIONCLASSIFICATION
Kazanjian(1938)
1.True(intraarticular):- fibrous or bony
adhesion between the articular surfaces
of TMJ.
2. False(extraarticular):- Results from
pathologic condition outside the joint,
that results in limited mandibular mobility.

13. Another classification
.
.
A 1. Fibrous
2. Fibroosseous
3. Bony
B 1. Partial
2. Complete

14. ETIOLOGYETIOLOGY
1. TRAUMA- Most common cause of
ankylosis. Trauma to the chin forcing
the condyle against the glenoid fossa,
particularly with bleeding into the
joint.
2. INFECTION- From middle ear &
mastoid (otitis media,mastoiditis).

15. 3. INFLAMMATORY-
. primary inflammation of the joint
. secondary to local inflammatory
process. (osteomyelitis)
.Secondary to blood streaminfections
- septicemia
- scarlet fever
- gonorrhea
. Rheumatiod arthritis

16. 4.NEOPLASTIC - (osteochondroma)
5.CONGENITAL
6.MYOGENIC – Myositis ossificans
produce limited opening.
7. NEUROGENIC – epilepsy,
brain tumour.

17. CLINIC FEATURESCLINIC FEATURES
• It includes –
. General features
. Unilateral features
. Bilateral features

18. GENERAL FEATURESGENERAL FEATURES
• AGE- Seen in young age (1 to 10 years)
• Symptoms – Trismus (inability to open
mouth)
. Oral problems – poor oral hygiene
carious teeth
periodontal problems
malocclusion

19. UNILATERAL FEATURESUNILATERAL FEATURES
1. Mouth opening is very limited
2. Asymmetry of face with fullness of
the affected side & relative
flattening of the unaffected side.
3. Face is deviated towards the
affected side.

20. 4. Chin is retracted on the affected side
& slightly bypass the midline.
5. Slight gliding movement towards the
affected side.
6. Cross bite is present.
7. Well defined antegonial notch on
affected side.

22. BILATERAL FEATURESBILATERAL FEATURES
• Bird face appearance/ micrognathia.
• No gliding movement neither
protrusive nor lateral movement.
• Presence of scar on the chin (possibly
due to trauma)

23. • Class II malocclusion, protrusive
incisors & anterior open bite.
• In a long standing case there is
atrophy or fibrosis of muscle.
• In congenital case-difficulty of
introducing the nipple into the mouth
of newborn infants.

25. Bird face
appearance
due to bilateral
TMJ ankylosis

26. HISTOPATHOLOGYHISTOPATHOLOGY
1. Atrophy or destructive changes in the
cartilagenous component of the joint with loss
of meniscus.
2. Normal soft tissue is replaced by thick
fibrous bands.
3. An overall flattening of articulation.
4. Glenoid fossa & articular eminence become
less pronounced.
5. The condyle become enlarged, composed of
dense sclerotic bone.

27. INVESTIGATIONSINVESTIGATIONS
• For definitive diagnosis & to confirm the
extent of bony growth imaging may be
required.
1. Lateral oblique view
2. O. P. G. view
3. Cephalometric radiograph
4. Submentovertex view
5. PA view
6. C T Scan

28. • FINDINGS –
1. Decreased ramus height on
the affected side.
2. The joint space is completely
or partially obliterated with
dense sclerotic bone.
3. The condyle can be replaced by
shapeless mass of bone.

29. 4. Prominent antegonial notch on the
affected side of mandible.
5. Elongation of coronoid process.
6. Sometimes A transverse or oblique dark
line crossing the mass of dense bone
showing fibrous ankylosis.

30. MANAGEMENTMANAGEMENT
• Ankylosis can only be treated surgically
there is no form of pharmacological
management.
• The type of surgery depends on the
patient & extent of deformity.
• Treatment also varies if ankylosis is
unilateral or bilateral.

31. Surgery for ankylosis is done in two
stages
1. in first operation only a release of
ankylosis is done, Jaw mobility is
brought about.
it is belived that growth takes
place after ankylosis release.
2. Second procedure, an orthognathic
surgery can then be planned to restore
facial esthetics. (especially in children)

32. GOALS OF TREATMENTGOALS OF TREATMENT
1. To create mobility in the joint to a
satisfactory limit.
2. To restore vertical height of the ramus.
3. To restore the mandible & TMJ to normal
anatomic & functional state.
4. To create a new joint space.
5. To allow the jaw to grow normally in child
treated for ankylosis.
6. To restore the facial esthetics.
7. To prevent recurrence of ankylosis.

33. SURGICAL PROCEDURESSURGICAL PROCEDURES
It includes
1. Condylectomy
2. Gap Arthroplasty
3. Interpositional Arthroplasty

34. CONDYLECTOMYCONDYLECTOMY
• This is a procedure done in ankylosis where the
anatomic feature of the joint are not
completely changed as in areas of fibrous.
• COMPLICATIONS-
1.Loss of vertical height of ramus
2. in bilateral condylectomy it create an
anterior open bite.
3. In unilateral condylectomy there is
deviation of the jaw on opening.

35. GAP ARTHRPLASTYGAP ARTHRPLASTY
• Gap arthroplasty involves creation of an
anatomical gap in the ankylosed segment to
form an artificial joint space.
• The gap is created at a level lower than the
original joint space.
• Two horizontal bony cuts are made in the
most superior aspect of the ramus and the
wedge of bone.
• A gap of 1-1.5 cm. is created & first
interposed with any material.

36. • COMPLICATIONS-
1. Chances of creating excessive gap
& reducing vertical height of ramus.
2. Anterior open bite due to excessive
bone removal.
3. Reankylosis due to bony contact b/w
the cut ends.

37. INTERPOSITIONALINTERPOSITIONAL
ARTHROPLASTYARTHROPLASTY
• Placing the interpositional material
material b/w the two cut ends avoids
contact b/w the bony ends.
• It minimises the chance of reankylosis.
• I.P. material may be-
biological- dermis, facia lata, bone &
cartilage.
Alloplastic- Vitallium, Tantalum,Silastic
& Acrylic.

38. COMPLICATIONS-
1. Second surgical site is necessary.
2. Foreign body reaction to alloplastic
material.
3. Difficulty in suturing or stablizing
the interpositional material on
the medial aspect of joint.
4. Doner site complication such as
pleuritic pain, pneumothorax.

39. SURGICAL APPROACHSURGICAL APPROACH
• Preauricular approach
• Risdon’s submandibular approach
• Temporal approach
• Post auricular approach
• Endural approach
• Retromandibular approach(post ramus)

40. OPERATION BY TEMPORALOPERATION BY TEMPORAL
APPROACHAPPROACH
1.It is the approach through a curvilinear
preauricular incision, extending 3 cm. long
into the temporal region for the exposure
of temporal facia.
2.The dissection of soft tissue is proceeded
up to zygomatic arch.
3.The capsule of the joint is opened with a T
shaped incision of the facia.

41. 4.Once the joint region is exposed and
ankylosed site is identified, aggressive
excision of the fibrous & bony mass
carried out.
5. Special attention is directed to the
medial extension of the callus to ensure
adequate excision.
6. Glenoid fossa is recontoured as needed.
7. Coronoidectomy & stripping of muscles
are done.

42. 8.It is observed that nearly 1/3 of the
height of the ramus is lost following
condylectomy & coronoidectomy.
9.Costochondral graft is removed
through inframammary incision.
10.Through submandibular approach
ramus is exposed.
11.Masseter & temporalis are stripped
from the ramus.

43. 12.Then the surface of the graft and
ramus are freshened to produce good
bony interface.
13.The graft is placed in position & fixed
with stable internal fixation so that
2mm. of posterior open bite is created
to compensate for remodelling of the
costochondral graft.

44. 14.The length of the graft is determined
by the ramus height discrepancy & the
facial asymmetry to be corrected.
15. A drain is placed & the wounds are
closed in layers.
16. After inter maxillary fixation for a
few days, jaw is mobilized vigorously &
physiotherapy is continued.

45. MANAGEMENT SUGGESTEDMANAGEMENT SUGGESTED
PROTOCOL(KABAN’S)PROTOCOL(KABAN’S)
1.Aggressive total excision of the
ankylotic segment in condylar/TMJ
region, incomplete removal, particularly
medial aspect result in recurrance.
2.Dissection & stripping of muscles of
mastication of the ramus & ipsilateral
coronoidectomy are essential.

46. 3. Inter incisial opening should be
critically evaluated to ensure that it
should be more than 35 mm.
4. If step 1,2,3 do not create enough
opening opposite side coronoidectomy
is done.
5. A suitable interpositional material must
be placed to avoid the risk of
reankylosis.
6. Reconstruction of ramus with
costochondral graft helps to maintain
the ramus height.

47. 7. Rigid fixation of the graft with ramus is
necessary for early mobilization of the joint.
8. Creation of open bite on affected side to
permit setting of graft for 3-6 months.
9. Early mobilization with minimum IMF less
than 3 weeks.
10. Post operative physiotherapy 6-8 weeks.

48. 11.If no further improvement is noticed
postoperatively, joint is stretched
under GA.(Brisement Force given.)
12.Later on, if needed, excessive growth
of the costochondral graft may have to
be recontoured so that no disturbance
in occlusion & jaw relationship develop.

49. REASONS OF RECURRENCEREASONS OF RECURRENCE
1.Incomplete excision of callus at the
ankylosed site.
2.If the mouth opening during surgery is
less than 35 mm & if coronoid process is
not excised, recurrence develops.
3.Insufficient & unsatisfactory
physiotherapy.

50. 4.Failure to maintain the ramus height
leads to narrowing of the inter-
fragmentory gap.
5.Failure to provide a satisfactory
interpositional material.
6.Heigher osteogenic & periosteal
reaction may be responsible for high
rate of recurrence in children.

51. COMPLICATION OFCOMPLICATION OF
ANKYLOSIS RELEASEANKYLOSIS RELEASE
SURGERYSURGERY
A. Preoperative consideration
B. Intra operative consideration
a. complication due to incision
b. complication during
osteotomy procedure.
c. Postoperative complications.

52. COMPLICATIONS DUE TOCOMPLICATIONS DUE TO
INCISIONINCISION
1. Damage to facial nerve.
2. Bleeding from superficial temporal
artery or facial vessels.
3. Damage to parotid gland.

53. COMPLICATIONS DURINGCOMPLICATIONS DURING
OSTEOTOMYOSTEOTOMY
1. Inadequate bone removal
2. Profuse bleeding from maxillary artery,
pterygoid venous plexus
3. Perforation of middle cranial fossa by
damage to glenoid fossa.

54. POSTOPERATIVEPOSTOPERATIVE
COMPLICATIONSCOMPLICATIONS
1. Anterior open bite or deviation of jaw.
2. Infection to surgical site.
3. Reankylosis.
4. Frey’s syndrome.

55. MANAGEMENT SUMMARYMANAGEMENT SUMMARY
1.Prior to 1951, it was considered to be
incurable.
2.Brisment force (forceful opening under
GA) was tried without success.
3.Esmarch suggested- wedge resection of
the body of the mandible.
4.Condylectomy in early cases.

56. 5. gap-arthroplasty led to recurrance.
6. osteoarthrotomy(gap & interpositional
arthroplasty) improved the prognosis.
7. Excision of callus & joint
reconstruction become the treatment
of choice.

57. R E F E R E N C E SR E F E R E N C E S
• B. SHRINIVASAN – Text book of oral
& maxillofacial surgery. (second edition)
• CHITRA CHAKARWARTI - Text book
of oral & maxillofacial surgery. (first
edition)
• ANIL GOVINDRAO GHOM- Text book
of oral medicine. (first edition)