TEMPOROMANDIBULAR

JOINT ANKYLOSIS AND

ITS MANAGEMENT
•INTRODUCTION

•CLASSIFICATION

•INCIDENCE

•AETIOLOGY

•PATHOPHYSIOLOGY

•CLINICAL FEATURES
•SEQUELAE OF TMJ ANKYLOSIS
•MANAGEMENT
Ankylosis (joint stiffness)
is the pathological fusion of parts of a joint resulting in restricted
movement across the joint

Ankylosis of the Temporomandibular joint, an arthrogenic

disorder of the TMJ, refers to restricted mandibular movements
(hypomobility) with deviation to the affected side on opening of
the mouth.
INCIDENCE
•Affects all age group but more in the first decade of life (0 – 10
years)

•There’s equal male and female distribution

•More common in Asian subcontinent

CLASSIFICATIONS
•Bilateral or Unilateral ankylosis

•Fibrous ankylosis or Bony ankylosis

•Intra-articular or Extra-articular ankylosis

•Complete or Partial ankylosis

•True or false ankylosis

AETIOLOGY

Trauma Systemic disease

-At birth (with forceps) -Small pox
-Blow to the chin (causing -Ankylosing spondylitis
haemarthrosis) -Syphilis
-Condylar fracture -Typhoid fever
-Scarlet fever

Infections and Inflammatory Others

-Rheumatoid Arthritis -Malignancies
-Septic arthritis -Post radiology
-Otitis media -Post surgery
-Mastoditis -Prolonged trismus
-Parotitis
-Osteoarthritis
PATHOPHYSIOLOGY

TRAUMA

Extravasation of blood into the joint space

haemarthrosis

Calcificatiion and obliteration of the joint space

Intra-capsular ankylosis Extra-capsular ankylosis

CLINICAL FEATURES
•Obvious facial deformity
•Deviation of chin towards affected side
•Inability to open the jaws, absent condylar movements
on affected side
•In unilateral ankylosis, the lower jaws shifts
towards the affected side on opening of the mouth
•Flatness or fullness on affected side
•Cross bite on ipsilateral side
•Class II malocclusion on affected side
RADIOGRAPHIC FEATURES

 Fusion of joint
 Loss of joint space

 Prominent antigonial notch

 Coronoid hyperplasia
 SEQUELAE OF TMJ ANKYLOSIS

•Facial growth distortion

•Nutritional impairment

•Respiratory disorders

•Malocclusion

•Poor oral hygiene

•Multiple carious and impacted teeth

MANAGEMENT

 Non surgical management

 Surgical treatment
SURGICAL MANAGEMENT

Aims and Objectives of surgery

To release ankylosed mass and creation of a gap

Creation of functional joint (improve patient’s oral hygiene,
nutrition and good speech)
To reconstruct the joint and restore the vertical height of the ramus
To prevent recurrence
To restore normal facial growth pattern
Procedures

1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty
CONDYLECTOMY
•Fibrous ankylosis
•Pre-auricular incision is made
•Cut at the level of the condylar neck
•The head (condyle) should be separated
from the superior attachment carefully
•The wound is then sutured in layers
•The usual complication of this procedure is an ipsilateral deviation
to the affected side. And anterior open bite if the procedure was
bilaterally.
GAP ARTHROPLASTY

 Extensive bony ankylosis.

The section here consists of two
horizontal osteotomy cuts
 removal of bony wedges for creation of a
gap between the roof of the glenoid fossa
and the ramus of the mandible.
This gap permits mobility
The minimum gap should be 1cm to
avoid re-ankylosis
INTERPOSITIONAL ARTHROPLASTY

This is actually an improvement/modification on gap arthroplasty

Currently the surgical protocol of choice
Materials are used to interpose between the ramus of the mandible
and base of the skull to avoid re-ankylosis
The procedure involves the creation of gap, but in addition, a barrier
is inserted between the two surfaces to avoid reoccurrence and to
maintain the vertical height of the ramus
MATERIALS USED IN INTERPOSITIONAL
ARTHROPLASTY

Autogenous Heterogenous Alloplastic

I. Temporalis muscles I. chromatised Metallic: tantalum foil

submucosa of pig’s and plate, stainless steel,
II. Temporalis fascia
bladder Titanium, Gold.
III. Fascia lata
 
IV. Cartiligenous grafts
II. lyophilized bovine Nonmetallic: silastic,
Costochondral
cartilage Teflon, acrylic, nylon,
Metatartsal
ceramic
Sternoclavicular
Auricular graft

V. Dermis
Autografts, such as skin, temporalis muscle, or
fascia lata, are presently considered the material
of choice for interposition.

Advantages of these flaps in TMJ reconstruction include

close proximity to the TMJ without involving an additional surgical
site.
 Complications of the surgery

Intra-Operative
Haemorrhage (damage of any superficial temporal vessels, transverse
facial artery, etc)
Damage to the external auditory meatus
Damage to the Zygomatic and temp. branch of facial nerve
Damage to the Auriculotemporal nerve
Damage to the Parotid gland
Damage to the teeth

Post Operative
infection
open bite
 RECURRENCE OF TMJ ANKYLOSIS
•Inadequate gap created between the fragments
•Fracture of the costochondral graft
•Inadequate coverage of the glenoid fossa surface
•Inadequate post-op physiotherapy
•Higher osteogenic potential and periostal osteogenic power may be
responsible for high rate of recurrence in children