TMJ ANKYLOSIS

AND ITS
MANAGEMENT
DR. SHARIQUE EQUBAL
PGT- FINAL YEAR
DEPT of OMFS
TMJ ANATOMY
▪ The temporomandibular joint is a diarthrodial,
ginglymal, synovial joint that allows both rotation
and translatory movement.
▪ It is formed by the articulation of the glenoid fossa
of the temporal bone and the head of condyle is
separated by fibrocartilaginous articular disc.

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TMJ
TTTT ARTICULATION CONSISTS OF

Bony components
▪ Glenoid fossa
▪ Condyle
Intra articular disc
Joint fibrous capsule
Extracapsular ligaments
▪ Lateral ligament
▪ Sphenomandibular ligament
▪ Stylomandibular ligament
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▪ Fibrous capsule
MOVEMENTS OF TMJ

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ANKYLOSIS
The term ankylosis is derived from the Greek word that means
stiffening of a joint as a result of a disease process, with fibrous
or bony fusion across the joint.

It is a pathological condition where the mandible is fused

to fossa by bony/fibrotic tissues .

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TMJ ANKYLOSIS INTERFERES WITH:-

▪ Mastication
▪ Speech
▪ Oral hygiene
▪ Growth and development

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“ ANKYLOSIS CAN BE
POTENTIALLY LIFE
THREATENING
WHEN WE WANT
TO ACQUIRE AN
AIRWAY DURING
AN EMERGENCY.
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EPIDEMIOLOGY

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ETIOLOGY

Forceps Scarlet
Otitis fever
delivery media

Intracapsular Meningitis
fractures Parotitis

Congenital Small pox

Mastoiditis
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OTHER ETIOLOGIES

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TRAUMA- The predominant cause of TMJ Ankylosis

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HOW TRAUMA LEADS TO TMJ ANKYLOSIS

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CLASSIFICATION OF TMJ
ANKYLOSIS
TYPE 1- Fibrous adhesion in and around
the joint, restricted condylar guiding

TYPE 2- Formation of the bony bridge

between the condyle and glenoid fossa.

TYPE 3-Condylar neck is ankylosed to

the fossa completely.

Modified by- TOPAZIAN

SAWHNEY CLASSIFICATION

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 RECENT
ADVANCEMENT

DONGMEI HE and
COLLEAGUES
(2011)

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 RADIOGRAPHIC
INVESTIGATIONS

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MANAGEMENT OF TMJ ANKYLOSIS

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SURGICAL ANATOMY OF TMJ

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SEQUALAE OF AN UNTREATED ANKYLOSIS

▪ Facial deformity
▪ Speech difficulty due to decreased mouth opening,
malocclussion and tongue position.
▪ Nutritional deficiency
▪ Respiratory distress
▪ Malnutrition
▪ Malocclusion
▪ Poor oral hygiene 23
TREATMENT AIIMS
▪ Restore mouth opening
▪ Restore joint function
▪ Allow for condylar growth
▪ Correct facial profile
▪ Relieve upper airway obstruction

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MANAGEMENT OF TMJ ANKYLOSIS

1. Gap arthroplasty with

coronoidectomy
2. Lateral gap arthroplasty
3. Interpositional arthroplasty
 Temporalis muscle and fascia
(Kaban and Perrot,1990)

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HISTORY OF TMJ ANKYLOSIS SURGERIES

ESMARCH- osteotomized the angle to release TMJ

ankylosis in 1851. The first inter-positional material
was the Pterygo-masseteric sling, also developed by
Esmarch.

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 Condylectomy was first advocated by
Humphrey in 1854.

Abbe performed the frst gap

Kaban and Colleagues described an
arthroplasty in 1880. But it
approach for the treatment of TMJ
was Topazian in the 1960s
ankylosis to minimize the incidence of
who signifed the importance
re-ankylosis and produce satisfactory
of interpositional grafts for
movement of the joint. Their study in
reducing re-ankylosis
1990 became a landmark management
protocol for the management of TMJ
ankylosis
Yet again in 2009, Kaban considered the
potential effect of time and growth (i.e.,
the fourth dimension) on the outcome of
TMJ ankylosis in children and presented 27

another protocol.
CONDYLECTOMY

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OSTEOARTHROTOMY (GAP ARTHROPLASTY)

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INTERPOSITIONAL ARTHROPLASTY

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RECONSTRUCTION OF RAMUS CONDYLE
UNIT

1. Autogenous condyle replacement 3. Distraction Osteogenesis for Ramus condyle unit

 Costochondral graft
 Sternoclavicular graft 4. TMJ bioengineering

 Iliac
 Metatarsal head

2. Allogenous joint replacement

 Acrylic
 Silicon
 Teflon
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 Metal- SS, titanium
COMPLICATIONS
▪ It is difficult to remove the actual extent of the
ankylotic mass as it is not properly assessed
medially.
▪ Chances of creating excessive gap and reducing
vertical height of ramus.
▪ Anterior open bite due to excessive bone removal.
▪ Re-ankylosis due to bony contact between the cut
ends. 35
2. LATERAL ARTHROPLASTY

▪ This involves resection of the

outer part of the ankylosed bone
from medial condyle malunion.

▪ It promotes rehabilitation of
mandibular function because the
remaining mandibular condyle
and disc function in articulation
with the glenoid fossa.
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3. INTERPOSITIONAL ARTHROPLASTY

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Materials used for Inter-Positional arthroplasty

▪ AUTOGENOUS ▪ ALLOPLASTIC
MATERIALS MATERIALS
 Costochondral ▪ 1. Non- metallic ▪ 2. METALLIC
graft  Acrylic  Titanium plate
 Metatarsal graft  Teflon  Stainless steel
 Sternoclavicular  Ceramic  Gold
joint
 Temporalis fascia
 Fascia lata
 Dermal fat 38

 Auricular cartilage
COMPLICATIONS
▪ Foreign body reaction with alloplastic
materials placed in surgical gaps.
▪ Difficulty in suturing from the medial aspect.
▪ Complications associated with second
surgical site in case of autogenous graft.
▪ Other complications as in gap arthroplasty.
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KABAN’S PROTOCOL FOR MANAGEMENT
TMJ ANKYLOSIS (1990)

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KABAN’S PROTOCOL FOR THE MANAGEMENT
OF TMJ ANKYLOSIS IN CHILDREN (2009)

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1. EXCISION OF THE ANKYLOSED MASS

▪ The TMJ is approached

through a preauricular
incision with a temporal
extension (hemi-coronal
incision).

▪ Reference- J. Oral Maxiilo-facial Surgeon 2009

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Aggressive resection of the bony mass is performed.

If any TMJ anatomy is identifiable, the superior osteotomy is

extended into joint to separate the ankylotic mass from skull
base.
If a sigmoid notch is identifiable, the inferior osteotomy is
created from notch, extending posteriorily at least 1.5-2cm
below the margin of ankylotic mass. 43
IPSILATERAL CORONOIDECTOMY
( Contralateral, if necessary)

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GLENOID FOSSA LINING

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 The deep temporalis fascia and the superficial muscle layers are
transferred to construct a barrier- to support the function of the
reconstructed ramus/ condyle unit and to maintain flap vascularity.
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The flap is sutured medially, anteriorly and posteriorly to
the soft tissues with 4-0 monocryl suture.
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RECONSTRUCTION OF RAMUS CONDYLE
UNIT

1. Autogenous condyle replacement 3. Distraction Osteogenesis for Ramus condyle unit

 Costochondral graft
 Sternoclavicular graft 4. TMJ bioengineering

 Iliac
 Metatarsal head

2. Allogenous joint replacement

 Acrylic
 Silicon
 Teflon
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 Metal- SS, titanium
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COSTOCHONDRAL GRAFT

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PROCEDURE

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Reconstruction of the
Ramus condyle unit is
achieved with a CCG
obtained by an infra-
mammary incision.
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The cartilaginous articulating surface of
the graft is then placed against the
temporalis flap through the
submandibular incision and rigidly
secured with 2mm- Titanium bone. 53
STERNOCLAVICULAR
JOINT GRAFTS

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Iliac Crest Grafts

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Vascularized Bone Grafts

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EARLY MOBILIZATION AND AGGRESSIVE
PHYSIOTHERAPY

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“RECENT MODIFIED KABAN’S PROTOCOL”

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DISTRACTION
OSTEOGENESIS
▪ Recently DO is gaining popularity in the
management of management of mandibular
hypoplasia subsequent to TMJ ankylosis.
▪ Postoperative stability is considered one of
the main advantage of DO.
▪ Gradual stretching of the surrounding soft-
tissue matrix, less periosteal stripping, and
positioning of osteotomy site distal to
pterygo-massetric sling have been
considered beneficial to the stability of
technique.
Reference-
Journal of Cranio-Maxillo-facial surgery
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FACTORS WHICH PREVENT RE-ANKYLOSIS: -

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One Staged Treatment

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Multi-Staged Treatment

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COMPLICATIONS OF SURGERY

INFECTION Haemorrhage Re- ankylosis

Damage to Stenosis of Perforation

facial and external in middle
auriculotemp auditory cranial
oral nerve canal fossa 74
COMPLICATIONS OF TMJ SURGERY

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FOLLOW-UP
▪ Periodic follow-up
and supervision
are important for
long-term success
and prevention of
re-ankylosis.
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THANK YOU!
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