TMJ Ankylosis Management and

Reconstruction

Dr. SUNDEEP SHARMA Dr. RAHUL KASHYAP

PRESENTER MODERATOR
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
S.G.T UNIVERSITY, FACULTY OF DENTAL SCIENCES
 Introduction
• Eleventh William Guy Memorial Lecture on 20
Feb, 1981 (Norman Rowe)

“ Ankylosis of the temporomandibular joint, is an

affliction which causes much misery for the
unfortunate victim, interfering with the
mastication and digestion of food, denying the
body the benefits of the balanced diet……If the
condition develops in the childhood, facial
deformity brings psychological stress which adds
to the physical handicap, thus disrupting family
life and creating emotional disturbance ”
 Definition

• From Greek word meaning stiffening of the joint as a result of

a disease process , with fibrous or bony fusion across the joint.
 Ankylosis

• Greek – ‘stiff joint’

 Terms used for Hypomobile jaw

• Trismus
• True ankylosis
• False ankylosis / Pseudo ankylosis
 What is pseudoankylosis?

• It is an interference with the joint mobility due to

fibrous adhesions within the joint – referred to as
fibrous ankylosis
Or
An extra articular cause
 Causes for extraarticular / pseudoankylosis

• Depressed zygomatic fracture

• Fracture dislocation of the condyle
• Adhesions of the coronoid process
• Hypertrophy of the coronoid process
• Fibrosis of temporalis fibers
• Myositis ossificans
• Scar contracture following thermal injury
• Tumor of the condyle or coronoid process
 ANATOMY OF
TEMPOROMANDIBULAR JOINT
ARTICULAR SURFACES:-
Upper surface :-
a) Articular eminence
b) Anterior part of the mandibular
fossa
ARTICULAR SURFACES:-

Lower surface:- Head of the mandible

•TMJ are bilateral diarthroidal joints (two articulating bone
components)

•It is a ginglymoid type of joint

 BONY COMPONENT

• Consist of glenoid fossa of the temporal bone & mandibular

condyle.
• condyle is roughly elliptical in cross section with
mediolateral width two times the anteroposterior width.
• The glenoid fossa is a smooth depression in the temporal
bone which is thinnest in its deepest part.
• Articular surface is covered by fibrocartilage.
 SOFT TISSUE COMPONENT
1) Intraarticular disc or Meniscus
2)Synovial membrane
3) Lateral pterygoid muscle
4)Capsule of joint

5) Ligaments- :

a) Temporomandibular (lateral) ligament

b) Sphenomandibular ligament
c) Stylomandibular ligament
d) Anterior malleolar ligament
NERVE SUPPLY:-
1) auriculotemporal nerve
2) masseteric branch of mandibular nerve

BLOOD SUPPLY:-
1) superficial temporal branch of external
carotid artery
2) middle meningeal artery
 Incidence

 High in India
 Age – 2 to 63 yrs
 Common before the age of 10 yrs.
 Incidence of trauma in ankylosis
• Rowes – 65%
• Sada – 58%
• El Mofty – 64%
• Sawhney – 70 cases of 69 were due to
trauma
Factors implicated in the genesis of ankylosis
following trauma to the mandible
(Laskin,1978)

1. Age

2. Severity of trauma

3. Site of fracture

4. Duration of immobilization

5. The articular disc

 Etiopathology of Ankylosis of TMJ

Trauma • congenital
• At birth (forceps delivery )
• hemarthrosis
• condylar # - intra / extra capsular

Infections • CSOM
• Parotitis
• tonsilitis
• Abscess around the joint
• osteomyelitis of the jaw
• actinomycosis
Inflammation • Rheumatoid arthritis
• osteoarthritis
• Septic arthritis

Systemic diseases • small pox

• scarlet fever
• Scleroderma
• beriberi
• Ankylosing spondylitis

Other causes • bifid condyle

• prolonged trismus
• prolonged immobilization
• Burns
PATHOPH

PATHOPHYSIOLOGY

TRAUMA

Extravasation of blood into the joint space

haemarthrosis

Calcification and obliteration of the joint space

Intra-capsular ankylosis Extra-capsular ankylosis

Pathophysiology contd…

•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 condylar

encapsulation with minimal
head and a narrowing of the joint space. destruction of the joint itself.

•Opposing surfaces then develop fibrous

adhesions that inhibit normal movements
and finally, may become ossified.
 Trauma
( Forceps delivery , injury involving neck of condyle )

Extravasation of blood in joint space

Clot organization

Calcification and obliteration of joint space

Ankylosis (extracapsular )
Immobilization (< 4 weeks )
Meniscus undergoes progressive destruction

Flattening of the glenoid fossa & thickening of the condylar head

Ankylosis (Intraarticular )
 INFECTION
Infection

Inflammation

leucocytic activity increases

lysozymal enzymes released

Tissue distraction, damage to synovial membrane

Necrosed tissue replacement by granulation tissue

granulation tissue filled the joint space, fiberosis occurs with time

ossification or calcification of the fibrotic mass

 • The incidence of ankylosis , following
condylar fractures in adults, is far less than in
children

• Why is this disparity ?

 Anatomical variations

Child Adult
 In children

• Cortical bone is very thin and the condylar neck

relatively broad.
• Immediate subarticular layer exhibits an interconnecting
plexus of blood vessels. An impact on the chin -imparted
to the condyle which then break up into small
fragments.

• Haemarthrosis is filled with highly osteogenic particles

 CLASSIFICATION

Based on the type of tissue involved

 Bony
 Fibrous
 Fibro- osseous

Based on the location

 Extra- articular
 Intra- articular
Based on the extent of fusion
 Partial

 Complete

Based on the side involved

 Unilateral

 Bilateral
By combination of location
By type of tissue involved
By extent of fusion
I. Kazanzian’s (1938)
Complete
True – intra articular
Incomplete

Bony
False – extraarticular
Fibrous
 Topazian classification (1966)

Type I: Fibrous adhesion in or around the joint restricted condylar

gliding.

Type II: Formation of bony bridge between the condyle & the glenoid
fossa.

Type III: Condylar neck is ankylosed to the fossa

completely
 Topazian’s three staged classification*
• Stage I: ankylotic bone limited to the condylar process
• Stage II : ankylotic bone extending to the sigmoid notch
• Stage III : ankylotic bone extending to the coronoid process

• *Topazian RG.Etiology of ankylosis of the temporomandibular joint:

analysis of 44 cases.J Oral Surg Anesth Hosp;22:227-233
 Rowe’s (According to the tissue involved)

 Fibrous ankylosis
 Fibro-osseous ankylosis
 Osseous ankylosis
 Cartilagenous ankylosis
 Osteo cartilagenous ankylosis
 SAWHNEY CLASSIFICATION (1986 )
1. Type I: Head of the condyle is flattened or deformed with close
approximation to the upper articular surface. Dense fibrous adhesions

2. Type II: Head misshapen or flattened but is distinguishable. Bony

fusion of head to outer edge of articular surface.

34
3. Type III: Bony block seems to bridge across ramus and zygomatic
arch. Displaced condylar head. Elongation of coronoid process seen.

4. Type IV: Bony block is wide and deep and extends between ramus and
upper articular surface thereby completely replacing joint architecture.

35
 Joram Raveh classification (1989)

• Class I : ankylotic bone tissue limited to the condylar process and

articular fossa

• Class II : the bone mass extends out of the fossa involving the medial
aspect of the skull base upto the carotid jugular vessels

• Class III : extension and penetration of the middle cranial fossa

• Class IV : combination of class II and class III.

 CLINICAL FEATURES

They vary according to the:

• Time of onset of ankylosis

• Unilateral or Bilateral
• Severity of ankylosis
• Duration.
 Problems faced in ankylosis
Difficulties in
• Speech
• Mouth opening
• Mastication
• Occlusal derangement
• Poor oral hygiene
• Rampant caries
• Generalised gingivitis
• Periodontal disease
• Gross calculi
• Difficulty in breathing
 Unilateral ankylosis

 Obvious facial asymmetry

 Deviation of chin on affected side

 Roundness & fullness of face
 Flatness and elongation on unaffected side
 Well defined antegonial notch
 Post cross bite
 Condylar movements absent on effected side
40`v
 Bilateral ankylosis
• Inability to open the mouth
• Mandible symmetrical but
micrognathic
• Bird face deformity
• Antigonial notch well defined
bilaterally
• Upper incisors protrusive with
ant open bite
• Multiple carious teeth with bad
PDL health
• Severe malocclusion , crowding
.
• Multiple Impacted teeth may be
found on radiograph
 • RECEDED CHIN - NECK
• BIRD FACE CHIN ANGLE ALMOST NIL
DEFORMITY 42
Clinical features contd…
Fibrous Ankylosis
Produced by adhesions within the TMJ affecting the
fibrous components
• Not usually associated with pain
• Limited range of motion on opening
• Deviated to the affected side
• Limited laterotrusion to the contralateral
side
• No radiographic findings other than
absence of ipsilateral condylar
translation.
Bony ankylosis
The union of bones of the TMJ by
proliferation bone cells, resulting in
immobility of the joint
• Not usually associated with pain
• More marked limitation on
opening
• There’s more marked ipsilateral
deviation
• There’s more marked limitation of
contralateral lateral movement
• There’s a radiographic evidence of
bone proliferation seen.
 Diagnosis

• History of trauma, infection etc.

• Clinical findings
• Radiographs – OPG, Lateral Oblique view, Cephalometric
radiograph, CT scan

• Recently, the value of three- dimensional CT (3D-CT) or

CBCT prior to surgery has been advocated.

44
 Plain radiographs

Orthopantomogram
PA Mandible
Lateral tomographic section
 CT – Scans of TMJ

Axial section
Coronal section
3 - D Reconstruction
Ankylotic mass

Marked antegonial notch

O Unilateral ankylosis

P
G

Bilateral ankylosis 49
 P
A
VI
E
W

Ankylotic mass

Shortened vertical
ramus height

Elongation
of the face
Deviated chin 50
Ankylotic mass

51
LATERAL CEPH.
Axial CT-scan showing bilateral TMJ ankylosis
52
Coronal CT-scan showing bilateral TMJ ankylosis

53
Coronal CT showing bony exostoses in the glenoid fossa
superiorly as well as medial on the condylar head, resulting in bony ankylosis

54
 3D CT

Left sided ankylosis, lengthening of face, deviation of chin

55
 3D CT

Coronoid hyperplasia, condylar fusion

56
CBCT (ANKYLOSED MASS WITH ELONGATION OF
CORONOID PROCESS
 HISTOLOGY FINDINGS

•A section of histology shows a fibrous connection, and new bone

formation.

•Intra-capsular ankylosis demonstrates irregular destruction of cartilage

and bone with lymphocytic infiltration.
 MANAGEMENT

• TREATMENT IS ALWAYS SURGICAL FOR

REGAINING SATISFACTORY FUNCTIONS
• LOT OF PROTOCOLS FOLLOWED AND MOST
WIDELY ACCEPTED IS “KABAN’S
PROTOCOL”
 KABAN’S PROTOCOL
[KABAN,PERROT & FISHER 1990]

• Kaban et al outlined the protocol for TMJ ankylosis in the year 1990
which was further modified in the year 2009.

• EARLY SURGICAL INTERVENTION

• AGGRESSIVE RESECTION(A GAP OF 1-1.5cm CREATED)
• IPSILATERAL CORONOIDECTOMY & TEMPORALIS MYOTOMY
• CONTRALATERAL CORONOIDECTOMY AND TEMPORALIS MYOTOMY
also performed [IF MAXIMUM INTRA INCISAL OPENING < 35mm]
• LINING OF GLENOID FOSSA REGION WITH TEMPORALIS FASCIA
• RECONSTRUCTION OF RAMUS WITH A COSTO CHONDRAL GRAFT
• EARLY MOBILISATION AND AGGRESSIVE PHYSIOTHERAPY [6 MONTHS
POST OP MINIMUM]
• REGULAR LONG TERM FOLLOW UP
• TO CARRY OUT COSMETIC SURGERY AT THE LATER DATE WHEN THE
GROWTH IS COMPLETED
 PROTOCOL FOR MANAGEMENT OF TMJ
ANKYLOSIS IN CHILDREN
1. Aggressive excision of fibrous and/or bony mass
2. Coronoidectomy on affected side
3. Coronoidectomy on opposite side if steps 1 and 2 do
not result in MIO of 35 mm
4. Lining of joint with temporalis fascia or the native disc,
if it can be salvaged
5. Reconstruction with either DO or CCG and
rigid fixation
6. Early mobilization of jaw; if DO used to reconstruct
RCU, mobilize day of surgery; if CCG used, early
mobilization with minimal intermaxillary fixation (not more than
10 days)
7. Aggressive physiotherapy

Kaban, Bouchard, and Troulis. Management of Pediatric TMJ

Ankylosis. J Oral Maxillofac Surg 2009.
• In 1999 El-Sheikh also outlined a new protocol based on whether
there was associated facial deformity that required correction
concomitantly or not.

• His series included children who had been diagnosed with ankylosis
early in life , patients who grew into adults with the handicap, and
adults who developed ankylosis later in life
His cardinal principles :

• The radical resection of the ankylosed mass via wide surgical

exposure
• Release of the pteryo-masseteric muscle sling (s) with resection of
the condylar processes
• Restoration of the vertical ramal height and condylar head by a
costochondral graft.
• Simultaneous correction of jaw bone deformities at the same time as
release of the ankylosis
• Careful selection of the patients who are expected to comply with
postoperative functional rehabilitation and regular follow up for
atleast 1 year.
Step 1 : Aggressive Resection
 Step 2 : Ipsilateral Coronoidectomy
• Dissection and stripping of muscle
temporalis , masseter, and medial
Pterygoid)

• Kent et al and Gurnalick and Kaban

recommended ipsilateral
coronoidectomy to prevent
inadequate intra-operative
interincisal mouth opening
 Step 3: Contralateral Coronoidectomy

• After step 2, MIO is critically evaluated . It should be

at least 35mm without force (passive opening)

• If this not achieved then comes step 3 of contralateral

coronoidectomy to achieve desired mouth opening.
 Step 4:lining of TMJ with Temporalis Fascia or
Auricular cartilage

• Consists of creating a new joint

lining

• Failure to replace the disc

allows direct contact between
the reconstructed condyle and
bony glenoid fossa

• According to authors this

increases the risk of reankylosis
 Step 5 & 6

• Reconstruction of the condyle with a

costochondral graft and securing it with
rigid internal fixation

Costochondral
graft
Step 7: Early mobilisation and aggressive
physiotherapy

THERA-BITE (Jaw Motion Rehablitation)

Surgical approaches to TMJ
1. Submandibular (Risdon’s)
2. Postramal (Hind’s)
3. Postauricular
4. Endural
5. Rhytidectomy approach Submandibular (Risdon’s)

Postramal (Hind’s)

Rhytidectomy approach
5. Preauricular
Dingman’s
Blair’s
Thoma’s
Popowich’s modification of Al – kayat & Bramley’s
6. Hemicoronal & bicoronal (Obwegeser’s)

Coronal Approach

Al – kayat & Bramley’s

Endaural Al-Kayat Bramley
 PRE AURICULAR INCISION
• ADVOCATED AND POPULARISED BY DINGMAN 1951
• MODIFICATIONS
• BLAIR’S INVERTED HOCKEY STICK[1936]
• THOMA’S ANGULATED INCISION[1958]
• AL-KAYAT & BRAMLEY[1979]
• POPOWICH & CRANE MODIFICATION OF AL-KAYAT
& BRAMLEY INCISION[1982]
AL-KAYAT & BRAMLEY[1979]
 Alkayat & Bramley’s incision
• Modification of preauricular
incision – upper part of incision
extended in question mark fashion-
for better access

• Mainly for ankylosis- wide area of

exposure & facilitates elevation of
temporalis flap for reconstructive
purpose
Popowich and Crane (1982) modified AlKayat and Bramley’s incision
Popowich modification of Al – Kayat
& Bramley’s approach
Advantages of Popowich modification of Al – Kayat &
Bramley’s approach

1. Reduction in incidence of facial nerve palsy

2. Provision for donor site for temporalis fascia
3. Dissection through avascular zone
4. Improved visibility (facial planes)
5. Good cosmetic result
6. Avoidence of auriculotemporal nerve anaesthesia
7. Reduction in total operating time
POST AURICULAR
 ENDAURAL APPROACH
RONGETTI’S MODIFICATION OF
LEMPERT’S APPROACH
POST RAMAL [HIND’S INCISION]
 SUB MANDIBULAR
APPROACH[RISDON]

Coronal section showing the layer
of dissection.
VII = relative position at temporal
branch during dissection.
Politi et al. Deep Subfascial Approach to the
TMJ. J Oral Maxillofac
Surg 2004
 Goal of surgical therapy

• Functional concerns.
• Correction of growth deformities in children.
• Aesthetic concerns of the patient.
 Aims and objectives of surgery

• Release of ankylotic mass and creation of a gap to mobilize the joint

• Creation of the functional joint

• To reconstruct the joint and restore vertical height of the ramus

• To restore normal facial growth pattern

(based on functional matrix theory)

• To improve aesthetics and rehabilitate the patient

 Surgical treatment concerns

• Children – functional and growth

• Adults – functional and aesthetic
 Surgical treatment in children
• 2 objectives
• To improve mandibular function
• To maintain normal growth and development
of face
 Guide lines for TMJ ankylosis management in
children*
• Ankylotic mass should be removed as early as possible
• Costochondral graft is the best material but should not be used before
the age of 7 years
• Facial deformity should be corrected only after 15 years of age
• Long- term physiotherapy is very important
• Post-op excercises should be started early ( first day after the
procedure if possible) and continued till one year
• Intermaxillary fixation should be avoided
• Mandibular deformities can be corrected in a second procedure

*Comparison of different materials for interposition arthroplasty in treatment of TMJ

ankylosis surgery: long term follow-up in 25cases C.Chossegros, L. Guyot,F.Cheynet,
BJOMS(1997)35, 157-160
 SURGICAL PROCEDURES

CONDYLECTOMY
GAP ARTHROPLASTY
INTERPOSITIONAL ARTHOPLASTY
TMJ RECONSTRUCTION
a) Autogenous
b) Alloplastic
Condylectomy
Indications- Fibrous ankylosis
demarcation between the roof of the glenoid fossa and head of the condyle is seen.
• Gap arthroplasty :
Resection of the osseous mass between the articular
cavity and the mandibular ramus.
• Interpositional Arthroplasty:
Creation of gap by resecting the osseous mass
followed by interposition of a biological (e.g.
temporal muscle flap) or non-biological material
(acrylic , silastic)
• Joint Reconstruction:
Resection of the osseous mass and reconstruction by
autogenous bone grafts or by total joint prosthesis
 Gap arthroplasty*
Advantages
• Simplicity
• Short operating time
Disadvantages
• Creation of pseudoankylosis
• Failure to remove all the bony pathology
• Increased risk of reankylosis

• Leonard B Kaban , David H Perrott and Kieth Fisher: A protocol for management of
temporomandibular joint ankylosis J Oral MaxilloFac Surg 1145- 1151,1990
 Interpositional arthroplasty
Advantages: same as gap arthroplasty
Disadvantages:
• Donor site morbidity
• Risk of foreign body reaction
• Failure to remove all the bony pathology
Steps in gap Arthroplasty
Steps in gap arthroplasty
 Interpositional Materials

Autogenous Heterogenous Alloplasts

1 Cartilagenous grafts 1 Chromatised 1 Metallic

 costochondral submucosa of pig  Tantalum foil/plate

 Metatarsal
bladder  316L stainless steel

 Sternoclavicular
2 Lyophilized Bovine  Titanium
cartilage
 Auricular cartilage  Gold
(still under research)
2 Temporal muscle 2 Nonmetallic
3 temporal fascia Silastic
4 Fascia Lata teflon
5 Dermis Acrylic
Nylon
Proplast
Ceramic implants
 1

13

16

Costochondral Temporalis Masseter

Costochondral graft Temporalis muscle and fascia

Interposition with temporalis muscle and fascia flap
Interposition with temporalis muscle and fascia flap
 Literature on tempoalis muscle and
fascia flap
• Advantage
autogenous nature
resilience
adequate blood supply
proximity to the joint – pedicle transfer

• Harvested as an axial flap based on the middle and deep temporal

arteries and veins
• First demonstrated by Tessier about various possibilities of this flap.
 Numerous variations of this flap -
K.Su-Gwan treatment of temporomandibular joint ankylosis with temporalis muscle and fascia
flap Int .J.Oral Maxillofac.Surg.2001;30:189-193

• 1989, Feinberg & Larsen – pedicled temporalis flap and

pericranial flap
• Pogrel & Kaban – included only fascia or both fascia and
muscle
• Bergey & Braun – posterior zygomatic arch can be
osteotomised and segment of arch removed, replaced and
secured with reigid fixation
• Hebrosa & Rotskoff , Brusati, Umeda, Clauser and Ziccardi

• Temporalis muscle and fascia flap in the treatment of U/L

TMJ ankylosis in adults is as important as choosing
interpositional arthroplasty.
Auricular cartilage graft interposition after TMJ
ankylosis surgery in children
 Gap arthroplasty
Vs
Interpositional arthroplasty
Comparison of studies
 Functional restoration by gap arthroplasty in temporomandibular joint
ankylosis – A report of 50 cases Ajoy Roychoudhary, Hari Prakash, AIIMS , New Delhi OOO
1999;87:166-9

Purpose :
To determine long-term results of gap- arthroplasty with
coronoidectomy followed by immediate post-op exercises.

Conclusion :
• The long-term results of gap arthroplasty are satisfactory and
comparable to those obtained through use of other treatments.
• Post-op excercises play a cruci.al role in lasting success
• Temporomandibular joint reconstruction
 Gap versus interpositional arthroplasty for ankylosis of the
temporomandibular joint- Letters to the editor ; April 2001:
388

• Richard G.Topazian:
“ My further experience , and that of other surgeons confirms a recommendation that
interposition arthroplasty is the preferred treatment for TMJ ankylosis ”
• Ajay Ray choudhary :
– Heterotrophic bone formation is a reality – irrespective of the treatment procedure

– Even the interposition of temporalis muscle flap is insufficient to ensure functional

results if the procedure not followed by active and passive physiotherapy

– Interpositional arthroplasty is not a panacea for this crippling disease and gap A is
supported by studies
 Temporomandibular joint Reconstruction

• Autogenous tissues
• Alloplastic materials
Autogenous tissues for reconstruction- The use of autogenous tissues for
temporomandibula Joint reconstruction –Robert Bruce MacInthosh J
Oral Maxillofac Surg 58; 63-69,2000

• Harvested ribs
• Muscle – 83%
• Autogenous fat - Murphy
• Fascia
• Dermis – Georgiade (92%)
• Metatarsal
• Costochonral graft –Ware and Brown Costachondral graft
 Costochondral graft
• Described by Gilles in 1920
• Ware and Brown prompted its use as a potential growth centre for
the mandibular joint.
• costocondral grafting should be preferred in growing child and as an
initial choice of reconstruction in many adult deformities.
• Disadvantages
1. Unpredictable growth pattern
2. Progressive dental midline shift , occlusal changes , chin deviation
and enlargement of the graft itself.
HARVEST OF COSTOCHONDRAL GRAFT

1. 5th or the 6th rib is harvested

2. inframammary skin crease is selected

3. subperiosteal elevation done

4. 4cm of the rib with a cartilagenous cap of 5mm is

resected

5. placed lateral to the ramus of the mandible through

risdons incision
 Advantages:
• It has biologic and anatomic similarities to the condyle.

• It has low morbidity of donor site.

• Numerous donor sites are available.

• It is easy to obtain and quick to adapt.

• Regeneration of donor site is possible.

• Retains integrity after transplantation

• Demonstrated growth potential in juvenile series.

 Disadvantages
• Pneumothorax

• Difficulty in placement of graft in nonexistent or rudimentary glenoid fossae, as

well as attachment to rudimentary or severely malformed ramus.

• Difficult placement in areas with. scarring, poor vascularization, and deficient

soft-tissue envelope.

• Difficulty in orientation of rib in graft site

• Dislodgment of graft laterally or superiorly.

• Pain

• Infection

• Uncontrolled and non predictable growth.

• Fracture of the costochondral joint.

 STERNOCLAVICULAR JOINT GRAFT

• Snyder and associates (1971)

• Wolforde and collegues(1994)
• Longitudinal incision 1 cm above and parallel to the clavicle
• 6-8cm lateral to the manubrium to harvest the medial 1/3rd of the
clavicle
• The muscle attachments are released, exposing the joint capsule.
• The articular disk and approximately 1 cm of ligamentous
attachments of the sternoclavicular capsule are preserved at the head
of the clavicle, the sternoclavicular junction is preserved.
• A reciprocating saw is used to complete the osteotomy through
the anterior and posterior cortical plates of the clavicle.

• The osteotomy is extended medially through the head of the

condyle near its midpoint, with care taken to preserve the
articular disk.

• The articular disk is sectioned with a scalpel to preserve the

portion overlying the harvested calvicular head.
 Metatarsal head Graft
• Metatarsal transplants have been used to reconstruct the
ramus condyle unit based on their morphologic similarity
to mandibular condyle.
• 1954- Dingman and Grabb replaced the deformed
mandibular condyle in 5 children.
• Due to short length of metatarsal it is suitable in pediatric
population
• shaft of metatarsal is of sufficient length 4 to 6 cm.
• He used fifth metatarsal head with its cartilaginous
articular surface which provides satisfactory
transplantation for reconstruction of TMJ.
• The short length of available metatarsal donor tissue
restricts its use to pediatric patients requiring condylar
replacement.

• The distal second, third, or fourth metatarsal bones are most

suitable for reconstruction of the mandibular condyle.

• The metatarsal bones are excised distal to the cuboid-

metatarsal joint through a dorsal approach.
 CALVARIAL BONE GRAFT

Graft is taken from parietal bone using hemi/ bicoronal

approach
• The calvarial donor site is often in the same operative field
as the recipient site, and the graft can be harvested with a
straight or convex contour.
• In addition, cranial bone is more structurally rigid than
other autogenous grafts
• When compared with CCG the calvarial bone graft was
more resistant to loss of vertical height.
 Technique:

The parietal bone is approached using a hemi coronal flap for

unilateral reconstruction or a complete coronal flap for
bilateral TMJ reconstruction.
• A template is prepared preoperatively from developed
radiographic film to estimate the appropriate size of the
graft.

• A full-thickness cranial bone graft is harvested.

• TMJ arthroplasty is performed in the standard fashion to

correct the underlying deformity. The graft is fixed to the
native mandible using bone screws and a plate.
 GLENOID FOSSA LINING
DERMIS GRAFT
• Has been used as interpositional material for the repair of disc
perforation
• COMMON DONOR SITE –BUTTOCK,UPPER LATERAL
THIGH,GROIN.
• SPLIT THICKNESS SKIN FLAP is elevated with a Dermatome
set at 0.015 – 0.020 inches
• The underlying dermis is then removed with a second pass of
dermatome or with a free hand technique using a scalpel n
scissors
• Graft is at least twice the diameter if the recipient site to
compensate for contraction of the elastic fibers
• GRAFT REMOVED,TRIMMED & SUTURED.
• Wound is covered with a semipermeable membrane and
a pressure dressing for 7 days to ensure
revascularization of skin.
• Pt instructed to protect the donor site from sunlight for
6months to prevent hyperpigmentation
• Dermis at the upper an outer quadrant of buttock is
approximately 0.8 – 1.2 mm thick, and when folded on
itself usually of sufficient bulk to line the glenoid fossa.
• Dermal graft is sutured to the lateral pterygoid muscle
and to the tissue remnants.
 AURICULAR CARTILAGE

Advantages:

• It is biologically inert
• It has some bulk & thus can partially compensate for the
loss of posterior ramus height.
• It is easy to harvest & is in same operative field.
• The final graft can be well contoured to fit the anatomic
needs of a disc replacement.
 Technique

• Involves a linear incision on the posterior aspect of the helix of the

ear.

• The post auricular skin is elevated in suprapericondrial plane.

• A small elevator is used to dissect the anterior perichondrial layer

from the cartilage, and the graft is delivered.

• Perichondrium is left attached to the convex surface to maintain graft

integrity and maximize graft revascularization and cell viability.
• The convex surface, which is covered by perichondrium, is
placed against the glenoid fossa
• The concave portion of the graft is against the mandibular
condyle.
• The lateral aspect of the graft is sutured to the joint capsule
or to the edge of the temporal fascia.
• A small drain is placed in the ear wound and the skin
incision is closed in standard fashion.
 TEMPORALIS MYOFASCIAL FLAP

• Commonest interpositional material

• Advnt – ease of elevation, reliable blood supply, proximity to
maxillofacial structures, fan shape nature provides wide arc of rotation
• INCISION –AS FAR SUPERIORLY as necessary to give proper
length for lining the joint.
• DISSECTION – INCLUDING FASCIA OR MUSCLE AND
FASCIA.
• FLAP EXTENDED – ZYGOMATIC ARCH.
• SUTURED- 5-0 RESORBLE.( 6 sutures placed)
• SUCTION DRAIN – 24-48 HRS.
 Fibular Free Flap

• microvascular
• viable and effective means of restoring function
Wax et al: Retrospective Analysis of TMJ
Reconstruction with Free Fibula Microvascular Flap.
Laryngoscope June 2000
 Iliac Crest

• Raja Kummoona: Chondro-osseus iliac crest graft for

one stage reconstruction of the ankylosed TMJ in
children. J Max Fac Surg, 1986
NEVER YAWN BECAUSE ITS
CONTAGIOUS!!!
 Condylar reconstruction in extensive ankylosis of TMJ in
adults using resected segment as autograft – A new technique
R.Gunaseelan Int J Oral Maxillofac Surg 1997 ;26 :405-407
 Alloplastic Reconstruction Materials

Gold foil used by Risdon in 1933 by interposing between

the bony surfaces
• Tantalun foil used by Eggers (1946) and Goodsell (1947).
• Vitallium - Castiglino and Kleitsch
• Stainless steel- Henry (1960)
• Christensen prostheses (1963)
• Teflon and Silastic - Small (1964)
• Tantalum foil- Hellinger (1964)
• Cast gold ramus condyle hemi articulation (1972)
• Dacron / Proplast - Teflon (VK - 1) 1983
• Chromium cobalt molybdenum RCD (1990
ALLOPLASTIC RECONSTRUCTION OF TMJ
Alloplastic condylar prosthesis
KENT-VITEK
DELRIN-Ti MESH
CHRISTENSEN TYPE 1 CHRISTENSEN TYPE 2
 Total joint prosthesis

• Mercuri et al found the CAD/CAM-fitted TMJ reconstruction system

to be a safe and long-term management .

• Tissue-engineered adult human mandible condyle composite of bone

and cartilage can serve as condylar substitutes in future.

• Long term follow up of CAD/CAM patient fitted TMJ rec. system,

JOMS:1440-1448,2002.
• Tissue- engineered compo. Of bone and cartilage for mandible
condylar rec.,JOMS:185-190,2001.
Custom Tech-Medica® prothesis on a
CADCAM
model
 Distraction in Ankylosis

• McCarthy used for mandibular. Lengthn. – hemifacial microsomia.

• Papageorge et al published a report in which reverse L corticotomy
was performed through the sigmoid notch , and distraction was
carried out successfully.

Simultaneous mandibular distraction and arthroplasty in a patient with

TMJ ankylosis and mand. Hypoplasia, JOMS:328-333,1999.
Gap arthroplasty with distraction osteogenesis
 Causes for Recurrence

• Inadequate exposure of the joint region and incomplete

excision of the callus at the ankylosed joint
• Fibrosis of the temporalis muscle
• Insufficient and unsatisfactory physiotherapy
• Failure to maintain the ramus height leads to narrowing of
the interfragmentary gap
• Failure to provide a satisfactory interpositonal material
• Higher osteogenic and periosteal reactions in children
 Postoperative care

• Airway and watchfulness for bleeding

• Mobilize as soon as possible

Physical therapy
CCG and DO – immediate postoperatively (active hinge
opening , lateral excursions , manual finger stretching ) –
4times 3-5mins.
6weeks postop- solid food , therabite jaw rehabilitation
system- 4-5 times , 3-5mins.
Heat ,massage , gum chewing.
• MIO no improvement at 6-8 weeks – jaw stretched under GA.
• 1 year physical therapy continued and followup
COMPLICATIONS OF TMJ
SURGERY

1) Pre-operative
2) Intra-operative
3) Post–operative
 PRE-OPERATIVE COMPLICATIONS:-

• These are primarily related to the anesthesia and

feasibility of airway management.
• Aspiration of blood clot, tooth or foreign body
during extubation as throat cannot be packed prior to
surgery
• Falling back of tongue and obstructing airway.
 Intraoperative complications

1) Vascular injury & hemorrhage

2) damage to external auditory meatus
3) Damage to zygomatic & temporal branch of facial nerve,
auriculotemporal nerve
4)Damage to glenoid fossa , leading entry into middle cranial
fossa
5) Damage to parotid gland
6)Damage to teeth during opening of jaws wit jaw stretcher
 Postoperative complications

• Infection
• Open bite
• Recurrance of ankylosis
- Due to
-inadequate gap created between fragments
-missing of medial condyle stump & leaving it behind
# of costochondral graft
-loosening of graft due to improper fixation
-inadequate coverage of glenoid fossa surface
-inadequate postop physiotherapy
-higher osteogenic potential & periostel osteogenic power may be
responsible for high rate of recurrance in children.
 LONG TERM COMPLICATIONS

• Malocclusion :

- After conservative TMJ surgery – limited posterior open

bite.
- pt’s who have undergone menisectomy or aggressive
arthroplasty for bony ankylosis – anterior open bite.
- If there is no change for 6 months – orthodontics &
orthognathic surgery.
 Conclusion

• Ankylosis presents a formidable challenge to the oral and

maxillofacial surgeon.

• Overall treatment is a long- term project that includes the orthodontist

, oral and maxillofacial surgeon, pediatric dentist , psychologist and
physical therapist as part of the health care team.

• The patient’s post-operative commitment to physical therapy and jaw-

stretching exercises determine the ultimate success.
 References
• Maxillofacial surgery ,Peter Ward booth ,(vol 2)

• ORAL AND MAXILLO FACIAL SURGERY- FONSECA.VOL.4[TMJ]

• PRINCIPLES OF OMFS- PETERSON.

• COLOUR ATLAS OF TMJ PROSTHESIS. PETER.D.QUINN

• Atlas Oral Maxillofacial Surg Clin N Am 19 (2011)

• Oral Maxillofacial Surg Clin N Am 27 (2015)

• Nitzan DW ,tmj fibrous ankylosis following
orthognathic surgery , int j adult orthodont
orthognthic surgery 1989.
• Karras SC,concurrent osteochondroma of the
mandibular condyle & ipsilateral cranial base
resulting in tmj ankylosis ; joms 54;640-646,1996
• Kaban LB ;a protocol for management of
temporomandibular joint ankylosis;48;1145-
1191,1990
• Salins PC New perspective in management of cranio
mandibular ankylosis;int j oral maxillofacial surg
56;1104-1106, 1998