TEMPOROMANDIBULAR JOINT

ANKYLOSIS

BY
Prof. Dr. Ragia Mohamed Mounir
Professor of Oral Surgery Department
Faculty of Oral and Dental Medicine
Cairo University
 TEMPOROMANDIBULAR JOINT
ANKYLOSIS
Def.:
 Is chronic limitation, consolidation or
immobilization of mandibuar condyle.

 An organizing hematoma under the influence

of osteogenic periosteum may result in
fibrous or bony ankylosis
Types of ankylosis :-
1. True Ankylosis : ( Intra – articular )

 Is the result of formation of fibrous or bony adhesions

between articular surfaces of mandibular condyle:

a) Bony Ankylosis b) Fibrous ankylosis

2. False ankylosis : ( Extra – articular)

Results from pathologic condition outside the joint i.e.

pathology is not involving the articular surfaces of the
temporomandibular joint , it involves the joint
capsule, ligament, tendons , muscles , oral mucosa ,
adjacent bones.
 TRUE ANKYOSIS (INTRA_ARTICULAR )

Types :
 More common than false Ankylosis
 May be of bony union or fibrous union
 May be unilateral or bilateral

Incidence

 Age : 2-63 years old

Highest incidence 10-19 years onset is usually before the
age of 10 years

 Sex : Equally in both ♀= ♂

Etiology
Factors predisposing to Ankylosis are

1.Trauma
Incidence of trauma as etiologic factor ranges from 26% to 75%

2.Infection
Incidence of infection as etiology factor ranges from 41% to
68%

(1) Trauma
1. Trauma to the mandibular symphysis of body of the
mandible
2. Fall on chin or Body of the mandible is usually followed By :
 Pain and tenderness in front of the ear
 Restriction of mouth opening
 Gradual and progressive diminution of range of jaw
movements
 3. Trauma during birth of intra uterine life e.g. abnormal
position of the fetus lead to compression of T.M.J. also
injury during natural birth forceps delivery .

Infection
 Inflammation exists in the joint due to direct extension
of infection from surrounding structures via blood stream
may result in Ankylosis. The most common cause are:
1. Otitis media

2. Mastoiditis

3. Osteomyelitis of the ascending ramus

4. Abscess associated with the parotid, temporal

peritonsillar, and dental infections

5. Blood-born infections (septicemia ) are common in

children may lead to septic arthritis and Ankylosis.

6. Rheumatoid arthritis have been reported to lead to

Ankylosis, which is a disease of children and young
adults which has clear history of multiple joint
involvement
Clinical features
In unilateral Ankylosis
1. Shift of the midline of the mandible to the affected
side.
2. Presence of unusually prominent mandibular angle
3. Deep antigonial notch can be left at the lower
border and anterior to the angle on the affected
side.
4. Height of the mandibular ramus on the involved side
is reduced
5. Body of the mandible on the involved side is
reduced.
6. Teeth on the affected side are usually in distal
occlusion.
In bilateral Ankylosis

1. Patient has prominent maxilla and marked under

development of mandible which named bird's face
appearance
2. Vertical rami and body of the mandible are short due
to failure of the mandible to develop in all directions
3. Crowding of permenant teeth
4. Open bite
5. Retrognathia
6. Antigonial notches bilaterally are prominent
7. Inability to open mouth
Radiographic findings
1. In fibrous Ankylosis, evidence of destructive proliferative
changes in bony components of the joint are seen.

2. In bony Ankylosis

a. Dense sclerotic mass of bone involving mandibular

condyle and gleniod fossa.

b. In others it may extend to involve the coronoid process,

sigmoid notch and zygomatic arch .

3. Accentuation of antigoneal notch

4. Short and wide ramus of the mandible

Radiographic views:
1. Panoramic radiographs.
2. Tomogram sagittal
 Coronal
3. C.T. Scan
 According to X-ray Ankylosis can be classified into 3 grades:
Grande 1 :
 Ankylosis limited to head of the condyle and glenoid fossa
Grade II:
 Condyle and coronoid process are fused with glenoid fossa and
zygomatic arch respectively.
Grade III:
 Ramus is attached to base of the skull and sigmoid notch can not
be identified
Diagnosis of ankylosis :
1. History of injury or trauma to the jaw
2. Inability to open the mouth or marked limitation.
3. Slight motion of uninvolved side in unilateral ankylosis
4. In bilateral Ankylosis movement may be impossible ( bird
face appearance )
5. Asymmetry of the face (in unilateral)
6. Flattened face on unffected side.
7. Shift of the symphysis in unilateral toward the involved
side.
8. Shortening of vertical and horizontal ramus.
9. Deep antigonlal notch.
10. Decrease in joint space in radiograph
Treatment of Ankylosis :
T.M.J. Ankylosis respond only to surgical treatment designed
to separate fused mandible from temporal bone

Surgical techniques :
1. Condylectomy
2. Gap arthroplasty.
3. Inter position arthropalsty.

These are performed through:

Pre-auricular approach
Sub- mandibular approach
Combination of both.
1.Condylectomy :
 When the anatomy of the condyle is not totally disrupted,
and the Ankylosis is mainly fibrous condylectomy is the
preferred procedure.

2.Gap Arthroplasty:

 When the joint is massively fused no attempt is made to

remove the condyle, unless it will lead to fracture of thin
roof of the glenoid fossa and perforation into the middle
cranial fossa
Instead gap or interpostion arthtoplasty are alternative
procedures:

 In gap arthtoplasty a section of bone is removed from between

the fused joint and the remainder of the condylar neck.

 If the coronoid procesess is involved in the ankylosis, the bone cut

( ostectomy ) must be extended to include the process.

 Optimum width of gap is 1.0 cm to 2.0 cm are recommended

 Two parallel lines are cut beginning in the depth of sigmiod notch

and carried at 45º angle to posterior border of the ramus

3.Interposition Arthroplasty:
After completion of gap arthroplasty, a substance can
be interposed in the created gap as:

 Temporal muscle fascia

 Dermal graft.

 Costocondral cartilage.

 Silastic.

 This substance is attached to either raw surface by several

techniques, gap arthroplasty allow reconstruction of altered joint,
prevents recurrence and permits obliteration of dead space
 PSEUDO-ANKYLOSIS
Definition
Limitation of movement between two bones that is not due to
osseous fusion of the articular surfaces, but is secondary to a
pathologic change in the tissue outside the joint capsule

Causes
1. Fibrosis of the tissue near or around the joint is an
important cause it may due to traumatic incident or
therapeutic irradiation, this leads to formation of fibrous
adhesions or bands of scar tissue which leads to limited
mandibular mobility, Radiation for treatment of maxillary
tumour for instance involving the region of masticatory
muscles leads to fibrous adhesions of surrounding fascial
layers limitation of mouth opening
2.Bone Impingement :
A. Over development and elongation of coronoid process
causing the mandible to impinge on the posterior aspect of
the zygoma when opening is attempted.

B. Exostosis, hyperplasia and tumour of coronoid process.

C. Post-traumatic depressed fracture of zygomatic complex or

arch, this depressed fracture may impinge upon coronoid
process and impedes mandibular movement.

3.Neurogenic disorders :
 That lead to mandibular dysfunction epilepsy, brain
tumour, cerebro vascular accident these conditions cause
flaccid paralysis muscles.
4.Hysterical Trismus
 This condition is apparently produced from fright. This
psychoneurosis produce a picture of complete bony
ankylosis

5.Myositis ossificans
 It is unusual pathologic entity, it is of two types:

A. Localized type : involved single muscle which is usually

the masseter.

B. Generalized type: More than one muscle of ,mastication,

buccinatior may be involved.

 It starts by single severe trauma or repeated minor trauma,

leads to hematoma formation, then calcified and ossified
6. Muscle trismus due to infection of adjacent elevator
muscles of the jaw resulting from pericoronal
infection of lower 3rd molars, or submasseteric
abscess.

7. Myofacial pain dysfunction syndrome

8. Temporomandibular joint dysfunction : prolonged

limitation of opening due to meniscus malrelation.

9. Scleroderma: is a collagen disease of unknown

etiology characterized by fibrosis, hardening and
rigidity of the skin, subcutaneous tissues and
muscles. When the face is involved there may be
constriction of buccal orifice which in itself limit
mandibular movements
 SURGICAL APPROACHES TO
TEMPORMANDIBULAR JOINT

1.Pre-auricular incision
Where limited access to the jaw is required :

1. The skin incision (2.9 cm ) is vertical and lines in the

crease of the skin at the attachment of the face. So that
the resulting scar is not visible.

2. It leads to direct access to the T.M.J.

3. Provides maximum lateral and anterior exposure of T.M.J.

2.Post –autricular approach
 The incision is made behind the ear, and the cartilaginous
auditory canal is divided and the entire auricle is reflected
forwards. The T.M.J. is exposed from behind by reflecting
the parotid gland

Disadvantages:

1. Infection involving external auditory canal.

2. Stenosis and contraction of auditory canal.
3. Paraethesia of external pinna ( auricle).
4. Injury to parotid and facial n.
3. Sub –Mandibular approach ( risdon) :
 It is the approach of choice for subcondylar procedures
 Incision line is located about 1 cm below the angle of the
mandible, it extends forwards parallel to the lower border of
the mandible and curve backwards slightly behind angle.

4. Post –Ramal ( Retromandibular):

 Skin incison done 1 cm behind the ramus of the mandible
and 1 cm, below the lobe of the ear.
 Careful dissection should be done to avoid injury to
posterior facial vein.

5. Endural approach
 Incision is done in the intercartllagenous cleft between
tragus and hellx.
 Internal Derangement

Definition: Abnormal relationship of the articular disc to the

mandibular condyle, fossa and articular eminence interfering with

the smooth action or the joint .

Etiology:
 Acute trauma to the mandible due to exposure to external
violence.
 Micro trauma of TMJ due to MPD (Myofacial pain dysfunction
syndrome)
 Bruxism Hyper-activity of the superior head of the lateral
pterygoid muscle
 Abnormal occlusion: (Cross bite/deep bite! reverse bite)
Pathogenesis:-
 Spasm of the superior belly of lateral pterygoid leads to Pulling
the disc anteriorly
 Dysfunction of the collateral ligaments due to the muscle pull
Elongation of the ligaments
 Compression of the retro-discal tissues by the condyles
Staging of internal derangement
Stage Characteristics Imaging

Early Painless clicking Slight ADD w R

Early/ intermediate Painful clicking Early disk deformity

Intermediate Intermediate locking / frequent ADD w intermittent

pain Locking disk deformity

Intermediate/late Closed lock chronic pain ADD without R. disk

deformity abnormal bone
contour
Late Crepitus chronic pain D. deformity perforation
Treatment
o Conservative treatment
o Splint therapy
o Anterior repositioning splint (ARS )
o Arthrocentesis
Mechanism of action
1. Symptomatic TMJ IS often accompanied by accumulation of
inflammatory mediators within the synovial fluid
2. The goal of Arthrocentesis is to lavage and lyse the joint space
and remove theses mediators so It is necessary to adequately
irrigate the joint
Technique
1. Patient may be given conscious sedation or GA with auriculo
temporal block
2. External auditory canal is protected by cotton impregnated
with antibiotic
3. Landmarks
o The point of needle entry 10 mm forward form the tragus
and 2mm inferior
o Second point (outflow needle) 20 mm anterior and 10mm
inferior to the tragus
o 18 gauge needles are used .
Technique
4. The joint is inflated with several mms of solution
5. Then the outlow needle is inserted and the lavage is done
using 100 ml of solution
6. Solution used is (Saline or ringer's lactate solution steroids or
sodium hyaluronate)
7. During lavage manipulation of the jaw is mandatory
(Opening~. closing. Protrusive lateral excursion) to break
adhesion
8. Anti-inflammatory is prescribed, ,-
C. Arthroscopy
Could be used as a diagnostic or therapeutic measure
Arthroscopy could be use for the following procedures
1. Arthroscopic lysis and lavage
2. Arthroscopic arthroplasty
3. Arthroscopic removal of adhesion
4. Capsular release
5. Disc repositioning
Surgical treatment
1.Surgical relocation of anterioriy displaced disc by
 Meniscoraphy: Disk is secured and tightened to the
capsule
 Meniscoplasty:
Transection and plication of the posterior attachment of
the disk
OR Plastic reconstruction of tears and perforation
 Menisectomy : Total removal of the disk
 Menisectomy with graft reconstruction
Autoenous graft e.g. dermis . Auricular cartilage
temporlis muscle
Alloplastic graft e.g silicone