Case prsentationBilateral TMJ Ankylosis

Kanokporn TungsakulFaculty of Dentistry

Thammasat University

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Outlines

• History taking

• Extra-oral examination

• Intra-oral examination

• Radiographic examination

• Diagnosis

• Review literature

• Treatment plan

• Post-op

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History takingเพศ หญิง อาย ุ8 ปีCC: อ้าปากได้น้อยมา 8ปีPI: ตอนอายุ 1 เดือน พลดัตกจากแม่ พ่ึงสงัเกตว่าลกูอ้าปากได้น้อยตอนฟันน ้านมซ่ีแรกขึน้

3 ปี 5 เดือน Known case Lt TMJ ankyloses type III, มีแผนผา่ตดัตอนอาย ุ6 ปี

5 ปี เร่ิมมีปัญหาหายใจล าบากตอนนอน นอนกรนเสียงดงั ไม่มีหยดุหายใจ Dx เป็น OSA ใช้ CPAPPMH: เป็น Asthma ตอน 1 ปี หลงัจากนัน้แขง็แรงดี, ปฏิเสธการแพ้ยา, ได้รบัวคัซีนครบ และมีพฒันาการสมวยั

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Extra-oral examination

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Intra-oral examination

MMO=1mm

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OPG

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Lat ceph

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PA ceph

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CXR

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CT

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Diagnosis

• Bilateral TMJ Ankylosis

Lt. TMJ Bony ankyloses type IV

Rt. TMJ Fibrous ankylosis

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Review literature

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.

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Anatomy

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Anatomy (Cont.)14

Classifications

• Bilateral or Unilateral ankylosis

• Fibrous ankylosis or Bony ankylosis

• Intra-articular or Extra-articular ankylosis

• Complete or Partial ankylosis

• True or false ankylosis

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AetiologyTrauma

- At birth (with forceps)

- Blow to the chin (causing

haemarthrosis)

- Condylar fracture

Infections and Inflammatory

- Rheumatoid Arthritis

- Septic arthritis

- Otitis media

- Mastoditis

- Parotitis

- Osteoarthritis

Systemic disease

- Small pox

- Ankylosing spondylitis

- Syphilis

- Typhoid fever

- Scarlet fever

Others

- Malignancies

- Post radiology

- Post surgery

- Prolonged trismus

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Pathophysiology

Truma

Extravasation of blood into the joint space

haemarthrosis

Calcificatiion and obliteration of the joint space

Intra-capsular ankylosis Extra-capsular ankylosis

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Unilateral clinical features • Mouth opening is very limited• Asymmetry of face with fullness of the affected side &

relative flattening of the unaffected side.• Face is deviated towards the affected side.• Chin is retracted on the affected side & slightly bypass the

midline.• Slight gliding movement towards the affected side.• Cross bite is present.• Well defined antegonial notch on affected side.

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Bilateral clinical features

• Bird face appearance/ micrognathia.

• No gliding movement neither protrusive nor lateral movement.

• Presence of scar on the chin (possibly due to trauma)

• Class II malocclusion, protrusive incisors & anterior open bite.

• In a long standing case there is atrophy or fibrosis of muscle.

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Investigations

• 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

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Radiographic features

• Fusion of joint

• Loss of joint space

• Prominent antigonial notch

• Coronoid hyperplasia

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Radiographic features (cont)

In fibrous ankylosis In bony mass ankylosis

1. There is evidence of destructive +proliferative seen in bony compartments of TMJ

2. Haziness or narrowing of joint space

1. Overall obliteration of joint space

2. It will also show antegonial nocthinganterior to angle of mandible

3. Elongation of coronoidprocess

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Sequelae of TMJ ankylosis

• Facial growth distortion

• Nutritional impairment

• Respiratory disorders

• Malocclusion

• Poor oral hygiene

• Multiple carious and impacted teeth

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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

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Procedures

1. Condylectomy

2. Gap arthroplasty

3. Interpositional arthroplasty

Surgical management

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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.

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Gap arthroplasty• 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.

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• 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.

Gap arthroplasty (cont.)

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Interpositional arthroplasty

• Placing the interpositional 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.

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• Complications

1. Second surgical site is necessary.

2. Foreign body reaction to alloplasticmaterial.

3. Difficulty in suturing or stablizing the interpositional material on the medial aspect of joint.

4. Doner site complication such as pleuriticpain, pneumothorax.

Interpositional arthroplasty (cont.)

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Materials used in interpositional arthroplasty

Autogenous Heterogenous Alloplastic

I. Temporalis muscles

II. Temporalis fascia

III. Fascia lata

IV. Cartiligenous grafts

CostochondralMetatartsalSternoclavicularAuricular graft

V. Dermis

I. chromatised submucosa of pig’s bladder

II. lyophilized bovine cartilage

Metallic: tantalum foil and plate, stainless steel, Titanium, Gold.

Nonmetallic: silastic, Teflon, acrylic, nylon, ceramic

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Use of costochondral graft

• In children, after the release of the ankylosis. It is necessary to place a material that will allow growth

• A costochondral graft is harvested from the 5th

6th or 7th rib

• A costochondral junction about 1.5 cm is harvested and attached to lateral surface of ramus of the mandible to reconstruct the ramus

• Cosmetic surgery is carried out at the later date when the growth of the patient is completed.

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Complicatipon of costochondral grafting procedure

1. Second surgical site is necessary.

2. Difficulty in suturing or stablizing the interpositional material on the medial aspect of joint.

3. Doner site complication such as pleuritic pain, pneumothorax.

4. Excessive growth of graft beyond what is required. This can be minimised by taking not more than 1.5 cm of costochondral graft.

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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

Complications of surgery

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• 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

Recurrence of TMJ ankylosis

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Treatment plan

Follow-up

Surgery treatment under GA•Gap arthroplasty at Lt TMJ +Lt condylotomyand reconstruction at Lt TMJ with costochondralgraft•Rt condylotomy

Postoperative Physiotherapy•Patent should be encouraged to start active exercises of jaw as soon as it can be to lolerated(mouth gag, finger exerciser)

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2 wk post-op

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Thanks you

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