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Oral Surgery: Ankylosis of

The document discusses various topics related to ankylosis and dislocation of the temporomandibular joint (TMJ). It first defines ankylosis as the fusion of the mandibular condyle to the glenoid fossa, which can be bony or fibrous. For treatment of ankylosis, the goals are to release the ankylotic joint and reconstruct a functional joint. The document also discusses various methods for TMJ reconstruction. It then discusses anterior dislocation of the condyle, the mechanisms involved, and treatment approaches such as manual reduction or eminectomy to prevent recurrent dislocations.

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51 views9 pages

Oral Surgery: Ankylosis of

The document discusses various topics related to ankylosis and dislocation of the temporomandibular joint (TMJ). It first defines ankylosis as the fusion of the mandibular condyle to the glenoid fossa, which can be bony or fibrous. For treatment of ankylosis, the goals are to release the ankylotic joint and reconstruct a functional joint. The document also discusses various methods for TMJ reconstruction. It then discusses anterior dislocation of the condyle, the mechanisms involved, and treatment approaches such as manual reduction or eminectomy to prevent recurrent dislocations.

Uploaded by

علي صادق جعفر
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Dr.

Nazhat Mahmood
Oral surgery 5th
Stage

LEC.3

Ankylosis of the Temporomandibular


Joint

Ankylosis is the fusion of the mandibular condylar


head to the glenoid fossa. It results from a variety of
etiologies, such as trauma, surgery, or infection
(infectious aetiology mostly occurs via direct spread from
mastoiditis or otitis but rarely via the haematogenous
route).

Ankylosis can be bony or fibrous, complete or


partial. Reference to fibrous ankylosis is made
clinically and radiographically when the limitation in motion of
the joint is caused by fibrous adhesions or scar tissues
rather than actual bone formation. Fibrous ankylosis often
precedes bony ankylosis.

Treatment

The goals of treatment for TMJ ankylosis are to


release the ankylotic joint(s) and to reconstruct a functional
joint. In the adult with TMJ ankylosis, the procedure of
choice to release the ankylosis will depend on the type and
severity of the condition. In fibrous ankylosis, often
detachment of the fibrous scars and a coronoidectomy (or
coronoidotomy) provide good mouth opening.

The usual method for the treatment of bony ankylosis


is gap arthroplasty is by parallel cuts approximately 1 cm apart
from the sigmoid notch to the posterior ramus.
Interpositional muscle graft or alloplastic material can be
placed to reduce union.

13
Joint reconstruction

The goal of TMJ reconstruction is to restore the mandible and


TMJ to as near normal an anatomical state. On rare occasions
the TMJ requires reconstruction. To date no replacement
adequately replaces the normal TMJ.

TMJ reconstruction could be partial or total. Total joint


reconstruction is required where there is no functional joint
plus loss of ramus height. This may be necessary where
there has been severe trauma, ankylosis, tumour
resection or a developmental abnormality such as
hemifacial microsomia. To reconstruct the condyle different
bone grafts are used. Costochondral rib grafts combined
with interpositional temporalis muscle graft is the most
widely used method for growing children.

For adults, several alloplastic prosthetic joint


replacement systems have been devised to replace both
glenoid fossa and condyle. Some have had problems from
chronic foreign body giant cell reactions to the synthetic
materials. If one intends to reconstruct the joint with a custom
CADCAM-generated joint, the surgery is usually done in
two stages-gap arthroplasty and maxillomandibular fixation to
stabilize the occlusion and retain the gap-followed by CT for
custom fabrication of the TMJ prosthesis and surgical
implantation of the prosthesis. The stock prostheses eliminate
this two-stage treatment plan.

Surgery is not the endpoint of treatment. The postoperative


phase, as in all surgery, is very important and neglect in this
area is often a reason for failure. Analgesic and anti-inflammatory
medications are usually indicated and physical therapy
is essential, with jaw opening exercises plus lateral and
protrusive movement exercises. Reluctance and noncompliance
from the patient in following a thorough physical therapy
regimen are

14
often cited as the most contributing factors for reankylosis
or failure to achieve good mouth opening.

Dislocation of the
condyle

Anterior dislocations are the most common type of


dislocation and result in displacement of the condyle
anterior to the articular eminence of the temporal bone.
These dislocations are classified as acute, recurrent, or
chronic.

Acute dislocation usually results from extreme mouth


opening with yawning, dental extraction, vomiting, or
seizures. In anterior dislocations there is an interruption in
the normal sequence of muscle action when the mouth
closes from extreme opening. The masseter and
temporalis muscles elevate the mandible before the lateral
pterygoid muscle relaxes resulting in the mandibular
condyle being pulled anterior to the bony eminence and
out of the temporal fossa. Spasm of the masseter, temporalis,
and pterygoid muscles causes trismus and keeps the
condyle from returning into the temporal fossa. These
dislocations can be both unilateral and bilateral (fig.3).

Recurrent dislocation result from a similar mechanism in


patients with risk factors such as congenitally shallow
mandibular fossa, loss of joint capsule from previous
mandible dislocations, or hypermobility syndromes. Chronic
dislocations result from untreated TMJ dislocations and the
condyle remains displaced for an extended time period.

15
Articular
eminenca
Zурската
Articular disc
Suprameatal
spine

Lateral
pterygold
Candyle
Forous
capsule

Fig. 3

Most patients with condylar dislocation present with jaw


pain and trismus after extreme mouth opening or after a
direct blow to the jaw. In addition, patients describe
difficulty with speaking or swallowing, and malocclusion.
A history of previous dislocations, hypermobility syndromes,
or injury to the TMJ joint should be elicited from patients.

TMJ DISLOCATION...
REDUCING A DISLOCATED
JAW

Fig. 4
16
Acute dislocation is usually managed with manual reduction.
After wrapping thumb fingers with gauze, the dentist place
thumbs inside the mouth on the lower back teeth. The
other fingers are placed around the bottom of the lower
jaw. The dentist then presses down on the back teeth and
pushes the chin up until the jaw joints return to their normal
location. In bilateral dislocation it is better to start with one
side then attempt to reduce the other side. Intra-venous or
intra-muscular muscle relaxant might be beneficial with
resistant cases (fig.4).

Eminectomy

This procedure is used for recurrent jaw dislocation. The


approach is the same as for the plication procedure. The
joint eminence, which lies anteriorly to the fossa, has to be
well exposed. The eminence is then excised by a
combination of bur cuts and a fine osteotome (Fig. 5). The
theory is that by taking away this eminence over which the
joint head sticks, the joint head has no obstruction to prevent
its return into the fossa.
Eminectomy. The hatched line indicates the

Fig.5

17

Dautrey procedure

This procedure is another method of stopping TMJ


dislocation. The approach is again exposure of the joint via
the preauricular incision. The eminence is again exposed but in
this procedure the anterior part of the eminence, which is
attached to the zygomatic arch, is incised in a more vertical direction
(Fig. 6). This anterior portion is fractured-off and, still attached
anteriorly to the Zygomatic arch, is swung downwards and
wedged against the remaining eminence to augment the
eminence. In theory, because of the increase in eminence
height, the condyle is unable to dislocate. Other methods
of eminence augmentation have been described, for
example bone graft augmentation.

.
www.

The Dautrey procedure to increase the height of the


eminence.

Fig. 6

18

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