Download 01. Ankylosis of temporomandibular joint

Ankylosis of temporomandibular
joint: etiology, pathogenesis,
classification, clinical features,
diagnosis and treatment of
ankylosis. Contracture of the
mandible: etiology, classification,
clinical features, differential
diagnosis, treatment, prevention.
Dislocations mandible: etiology,
symptoms, diagnosis, treatment.
Temporomandibular joint,
(TMJ), an essential joint of the face, required for speech and
nutrition; a synovial joint formed by the mandibular fossa of the
temporal bone and the head of the condyle of the mandible
with an intervening articular disc. The joint surface is
completely covered by a thick fibrous capsule that allows for
range of movements.
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.
•Affects all age group but more in the first
decade of life (0 – 10 years)
•There’s equal male and female distribution
•Almost all cases are unilateral.
Trauma
- At birth (with forceps)
- Blow to the chin (causing
haemarthrosis)
- Condylar fracture
Infections and Inflammatory
- Rheumatoid Arthritis
- Septic arthritis
- Otitis media
- Mastoditis
- Parotitis
- Osteomyelitis
- Osteoarthritis
- Tonsillitis
Systemic disease
- Small pox
- Ankylosing spondylitis
- Syphilis
- Typhoid fever
- Scarlet fever
-
Others
Malignancies
Post radiology
Post surgery
Prolonged trismus
TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis
Extra-capsular ankylosis
•Intra-capsular ankylosis
•Extra-capsular ankylosis
•There’s destruction of the meniscus
and flattening of the temporal fossa
•There’s an external fibrous
•thickening and flattening of the
destruction of the joint itself.
condylar head and a narrowing of the
joint space.
•Opposing surfaces then develop
fibrous adhesions that inhibit normal
movements and finally, may become
ossified.
encapsulation with minimal
•Inability to open the jaws
•In unilateral ankylosis, the lower jaws shifts towards the affected
side on opening of the mouth
•In severe cases, there is complete immobilization
•There may be Abnormal forward protrusion of the mandible as the
excess tissues occupies the space
•Facial deformity
Others are related to the underlying cause of the ankylosis
•Fever
•Pain
•Other bones and joints deformities
Fibrous Ankylosis
Bony ankylosis
Produced by adhesions within the TMJ affecting
the fibrous components
The union of bones of the TMJ by proliferation
bone cells, resulting in immobility of the joint
• Not usually associated with pain
•
• Limited range of motion on
opening
pain
•
• Deviated to the affected side
• Limited laterotrusion to the
More marked limitation on
opening
•
contralateral side
• No radiographic findings other
Not usually associated with
There’s more marked
ipsilateral deviation
•
There’s more marked limitation
that absence of ipsilateral
of contralateral lateral
condylar translation
movment
•
There’s a radiographic
evidence of bone proliferation
•Speech impairment
•Facial growth distortion
•Nutritional impairment
•Respiratory disorders
•Malocclusion
•Poor oral hygiene
•Multiple carious and impacted teeth
 Non surgical management
 Surgical treatment
Aims and Objectives of surgery
 To release ankylosed mass and creation of a gap to mobilize the
joint
 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 re-occurrence
 To restore normal facial growth pattern
 To improve esthetic appearance of the face (cosmetic reason)
 Physiotherapy follow-up
Procedures
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty
CONDYLECTOMY
• This procedure is usually indicated when the joint space is obliterated
with the deposition of fibrous bands; but, there hasn’t been much
deformity of the condylar head. Usually employed in cases of fibrous
ankylosis.
• Pre-auricular incision is made
• Horizontal cut carried is out 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
 This procedure is employed in an extensive bony ankylosis.
 The section here consists of two horizontal osteotomy cuts
 And 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
INTERPOSITIONAL ARTHROPLASTY
MATERIALS USED IN INTERPOSITIONAL ARTHROPLASTY
Autogenous
Heterogenous
Alloplastic
I.
I.
chromatised
submucosa of pig’s
bladder
Metallic: tantalum foil
and plate, 316L stainless
steel, Titanium, Gold.
II.
lyophilized bovine
cartilage
Nonmetallic: silastic,
Teflon, acrylic, nylon,
ceramic
Temporalis muscles
II. Temporalis fascia
III. Fascia lata
IV. Cartiligenous grafts
Costochondral
Metatartsal
Sternoclavicular
Auricular graft
V. Dermis
Advantages of this procedure (interpositional arthroplasty)
 Autografts, such as skin, temporalis muscle, or fascia lata, are
presently considered the material of choice for interposition.
 In more recent years, a pedicled temporalis myofascial or
temporalis fascia flap has been advocated in TMJ surgery to treat
the TMJ ankylosis.
 Advantages of these flaps in TMJ reconstruction include
 close proximity to the TMJ without involving an additional
surgical site,

adequate blood supply,
 autogenous origin grafts can be used,
 and maintenance of attachment to the coronoid process, which
provides movement of the flap during function, simulating
physiologic action of the disc.
Advantages of this procedure (interpositional arthroplasty)
Post -OP
Complications of the surgery
Anaesthesia
 Aspiration of blood clot, tooth or foreign body
 Falling back of the tongue causing airway obstruction
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 Glenoid fossa
 Damage to the Auriculotemporal nerve
 Damage to the Parotid gland
 Damage to the teeth
Post Operative
 infection
 open bite
 re-occurrence of ankylosis
A restricted ability of the lower jaw
to move is designated as
contracture.
Forms of contracture:
Inflammatory contracture
Muscular contracture
Arthrogenous contracture
Fibrous contracture
Neurogenic contracture
Intra-Articular Causes
Ankylosis
Arthiritis Synovitis
Meniscus Pathology
Extra-Articular Causes
Infection:
Odontogenic- Pulpal
 Periodontal
 Pericoronal
Non-Odontogenic- Peritonsillar abscess
 Tetanus
 Meningitis
 Brain abscess
 Parotid abscess
Trauma
 Fractures, particularly those of the mandible and
Fractures of zygomatic arch and zygomatic arch
complex,Accidental incorporation of foreign bodies
due to external traumatic injury Treatment: fracture
reduction, removal of foreign bodies with antibiotic
coverage
TMJ Disorders
 Extra-capsular disorders – Myofascial Pain
Dysfunction Syndrome
 Intra-capsular problems – Disc Displacement,
Arthritis, Fibrosis, .. etc.
 Acute closed locked conditions – displaced meniscus
Tumors and Oral care
 Rarely, trismus is a symptom of nasopharyngeal or
infratemporal tumors/ fibrosis of temporalis tendon,
when patient has limited mouth opening, always
premalignant conditions like oral submucous fibrosis
(OSMF) should also be considered in differential
diagnosis.
Drug Therapy
 Succinyl choline, phenothiazines and tricyclic
antidepressants causes trismus as a secondary effect.
Trismus can be seen as an extra-pyramidal side-effect
of metaclopromide, phenothiazines and other
medications.
Radiotherapy and Chemotherapy
Complications of Radiotherapy:
 Osteoradionecrosis may result in pain, trismus,
suppuration and occasionally a foul smelling wound.
 When muscles of mastication are within the field of
radiation, it leads to fibrosis and result in decreased
mouth opening.
Complications of Chemotherapy:
 Oral mucosal cells have high growth rate and are
susceptible to the toxic effects of chemotherapy, which
lead to stomatitis.
Congenital / Developmental Causes
 Hypertrophy of coronoid process causes interference
of coronoid against the anteromedial margin of the
zygomatic arch.
 Trismus-pseudo-camtodactyly syndrome is a rare
combination of hand, foot and mouth abnormalities
and trismus.
Miscellaneous disorders
 Hysteric patients: Through the mechanisms of
conversion, the emotional conflict are converted into a
physical symptom. E.g.: trismus
 Scleroderma: A condition marked by edema and
induration of the skin involving facial region can cause
trismus
 Common causes
Lock-jaw caused due to muscle rigidity.
 Pericoronitis (inflammation of soft tissue around impacted third molar) is the
most common cause of trismus.
 Inflammation of muscles of mastication. It is a frequent sequel to surgical
removal of mandibular third molars (lower wisdom teeth). The condition is
usually resolved on its own in 10–14 days, during which time eating and oral
hygiene are compromised. The application of heat (e.g. heat bag extraorally,
and warm salt water intraorally) may help, reducing the severity and duration
of the condition.
 Peritonsillar abscess, a complication of tonsillitis which usually presents with
sore throat, dysphagia, fever, and change in voice.
 Temporomandibular joint dysfunction (TMD).[8]
 Trismus is often mistaken as a common temporary side effect of many
stimulants of the sympathetic nervous system. Users of amphetamines as well
as many other pharmacological agents commonly report bruxism as a sideeffect; however, it is sometimes mis-referred to as trismus. Users' jaws do not
lock, but rather the muscles become tight and the jaw clenched. It is still
perfectly possible to open the mouth.[8]
 Submucous fibrosis.
Lock-jaw caused due to muscle
rigidity.
Dislocation
Dislocation is a complete separation
of the articular surfaces with fixation
in an abnormal position.
Anterior dislocation of the condyle in
which the normal anatomic
relationships within the joint have
been completely disrupted occurs with
the condyle displaced and fixed
anterior to the articular eminence.
mandibular dislocation -- the condyle
(c) is anterior to the articular eminence
(e)
Causes:
• Deep yawning
• Prolong Dental procedures
• Airway manipulation particularly in an
anaesthetised patient.
• Dislocation can occur during laryngoscopy,
transoral fiberoptic bronchoscopy and
intubation.
Clinical features:
• TMJ dislocation may occur with trauma, but most
often follows extreme opening of the mouth
during yawning, laughing, singing, vomiting, or
dental treatment .
• Dislocation also can result from dystonic
reactions to drugs .
• Symmetric mandibular dislocation is most
common, but unilateral dislocation with the jaw
deviating to the opposite side also can occur.
• TMJ dislocation is painful and frightening for the
patient.
On examination:
• The patient is unable to close the mouth and there is
excessive salivation .
• A depression may be noted in the preauricular area.
• Palpation of the TMJ reveals one or both of the condyles
trapped in front of the articular eminence and spasm of the
muscles of mastication.
• Patients prone to mandibular dislocation include those
with an anatomic mismatch between the fossae and
articular eminence, weakness of the capsule and the
temporomandibular ligaments, and torn ligaments.
• Patients who have had one episode of dislocation are
predisposed to recurrence .
Diagnosis:
• The dentist bases the diagnosis on the position
of the jaw and the person's inability to close his
or her mouth.
• Radiographs of the TMJ are not always
necessary, but should be obtained to exclude
condylar fracture if the dislocation is related to
trauma
• The problem remains until the joint is moved
back into place. However, the area can be tender
for a few days.
Treatment :
• The muscles surrounding the temporomandibular joint
need to relax so that the condyle can return to its normal
position.
• Many people can have their dislocated jaw corrected
without local anesthetics or muscled relaxants. However,
some people need an injection of local anesthesia in the
jaw joint, followed by a muscle relaxant to relax the
spasms.
• The muscle relaxant is given intravenously (into a vein in
the arm). Rarely, someone may need a general anesthetic
in the operating room to have the dislocation corrected.
• In this case, it may be necessary to wire the jaws shut or
use elastics between the top and bottom teeth to limit the
movement of the jaw.
• To move the condyle back into the correct position,
a doctor or dentist will pull the lower jaw downward
and tip the chin upward to free the condyle .
• The doctor or dentist then guides the ball back into
the socket.
• After the joint is relocated, a soft or liquid diet is
recommended for several days to minimize jaw
movement and stress.
• People should avoid foods that are hard to chew,
such as tough meats, carrots, hard candies or ice
cubes, and advice not to open their mouths too
widely.
Prevention:
 TMJ dislocation can continue to happen in people with
loose TMJ ligaments. To keep this from happening too
often, dentists recommend that people limit the range of
motion of their jaws, for example by placing their fist
under their chin when they yawn to keep from opening
their mouths too widely.
 Conservative surgical treatments can help to prevent the
problem from returning.
 Some people have their jaws are wired shut for a period
of time, which causes the ligaments to become less
flexible and restricts their movement.
 In certain cases, surgery may be necessary.
 Eminectomy removal of the articular eminence so that
the ball of the joint no longer gets stuck in front of it.
 Another procedure involves injecting medications into
the TMJ ligaments to tighten them.
Prognosis:
• The outlook is excellent for returning the
dislocated ball of the joint to the socket.
• However, in some people, the joint may continue
to become dislocated , If this happens, needs
surgery.