Published on February 14, 2014
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 •There’s equal male and female distribution years) •More common in Asian subcontinent
CLASSIFICATIONS •Bilateral •Fibrous or Unilateral ankylosis ankylosis or Bony ankylosis •Intra-articular •Complete •True or Extra-articular ankylosis or Partial ankylosis or false ankylosis
AETIOLOGY Trauma -At birth (with forceps) -Blow to the chin (causing haemarthrosis) -Condylar fracture Systemic disease -Small pox -Ankylosing spondylitis -Syphilis -Typhoid fever -Scarlet fever Infections and Inflammatory -Rheumatoid Arthritis -Septic arthritis -Otitis media -Mastoditis -Parotitis -Osteoarthritis Others -Malignancies -Post radiology -Post surgery -Prolonged trismus
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 •Inability of chin towards affected side 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. I. Metallic: tantalum foil and plate, stainless steel, Titanium, Gold. Temporalis muscles II. Temporalis fascia chromatised submucosa of pig’s bladder III. Fascia lata IV. Cartiligenous grafts Costochondral Metatartsal Sternoclavicular Auricular graft V. Dermis II. lyophilized bovine cartilage Nonmetallic: silastic, Teflon, acrylic, nylon, ceramic
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
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