CLASSIFICATION OF TMJ ANKYLOSIS

1. FALSE ANKYLOSIS OR TRUE ANKYLOSIS 2. EXTRA ARTICULAR OR INTRA ARTICULAR 3. FIBROUS OR BONY 4. UNILATERAL OR BILATERAL 5. PARTIAL OR COMPLETE

False ankylosis may be caused by enlargement of the coronoid process, depressed fracture of the zygomatic arch, scarring from surgery, irradiation, infection, etc. True ankylosis of the mandible is one of the most disturbing articular pathosis of TMJ, causing many psychological and physical disturbances.

 Intra-articular

ankylosis indicates union between articular surfaces of the TMJ. Extra-articular ankylosis results from lesions involving extra articular structures.

 Bony

ankylosis- union of the bones of a joint by proliferation of bone cells, resulting in complete immobility Fibrous ankylosis- reduced joint mobility due to proliferation of fibrous tissue.

ETIOLOGY OF TMJ ANKYLOSIS

1.Trauma to the joint during an accident, fall etc 2.Trauma during birth, forceps delivery etc 3.Congenital or birth defect 4.Disease or infection in the joint, ear infection etc 5.Enlargement of the coronoid process 6.Depressed fracture of the zygomatic arch, condylar neck fracture etc 7.Surgery to or around the joint 8.Rheumatoid arthritis 9.Ankylotic conditions such as ankylosing spondylitis may also be inherited. 10.Destruction of the joint cartilage

Signs and Symptoms of TMJ Ankylosis

The problems that arise with the TMJ Ankylosis are psychological, morphological, Aesthetic and functional. The restricted function of the joint would affect the jaw movement.

1.Restricted movements of the jaw, the mandible due to the condyle fusion in the TMJ .2.Inadequate chewing function 3.Restricted mouth opening 4.Poor maintenance of oral hygiene 5In severe cases, problems in speech 6.In children, reduced growth of mandible results in Bird Face 7.If single side is affected, facial asymmetry is seen 8.Misaligned teeth, due to lack of enough space in the jaws 9.Emotional, social, psychological disturbances

Types

RADIOGRAPHIC FEATURES
Radiographic examination is also an important part in the clinical assessment and diagnosis of the TMJ Ankylosis. Although there are no specific radiographic features seen, the joint still would show an irregularly shaped condyle of the mandible, and even there is a dense bone filling in the joint space which is indicative of the restricted movement of the mandible.

Treatment of TMJ Ankylosis

There are various treatment procedures for the TMJ Ankylosis and this condition can be corrected using different surgical and non-surgical methods.
Excision

of the Ankylosis via Gap Arthroplasty

In Gap Arthroplasty no substance isinterposed between the two cut bony surfaces. Section consists of two horizontal osteotomy cuts and the roof of the glenoid fossa and ramus. Minimum of 1 cm gap is created to prevent reankylosis.bone is removed by using a large round bur, until the medial bone is thinned out enough to be readily removed by using hand chisel or osteotome.

CONDYLECTOMY
It is advocated in cases of fibrous ankylosis, where the joint space is obliterated with the ddeposition of fibrous bands but there is not much deformity of the condylar head.

If the Ankylosis is intra-articular and the coronoid process is involved, the Condylectomy is done, and if the the coronoid process along with the zygomatic arch are involved, the osteotomy of the coronoid process along with a part of the ramus is done.

 Total

condylectomy followed by the replacement of the joint using autogenous, alloplastic, allogenic material. If the condition is unilateral, the treatment is not as complex as that of the bilateral ankylosis, because the bilateral has not just the problem of the joint but also the development of the jaw and chin is affected and that needs to be corrected.

CORONOIDECTOMY
This is the excision of the coronoid process of the mandible to release the temporalis muscle.

 Therapeutic treatment (biphosphonates, NSAIDS) and physiotherapy to discourage reankylosis of the joint is very important after any surgical corrections. Patient compliance to the postoperative physical therapy is essential to success of any surgical treatment. Jaw-opening exercises must be performed for months to years to maintain the normal mouth opening.

INTERPOSITIONAL ARTHROPLASTY
It involves the creation of a gap and a barrier is inserted between the cut bony surfaces to minimize the risk of recurrence and to maintain the vertical height of ramus.

Inter-positioning of the TMJ with temporal fascia or cartilage maybe done to prevent reankylosis of the joint. In cases of bilateral true ankylosis, the treatment is more complex. Facial deformity and asymmetry can be corrected by bone grafts, distraction ontogenesis, orthognathic surgery --- saggital split osteotomy, genioplasty, or Extended-sliding genioplasty.

Problems Associated with TMJ Ankylosis

1. Restricted jaw movements 2. Inadequate masticatory (chewing) function 3. Restricted mouth opening 4. Inhibited facial and physical growth 5. Impaired speech 6. Reduced growth of mandible resulting in Bird Face 7. Facial asymmetry if only one side is affected 8. Difficulty in breathing and swallowing 9. Snoring and difficulty in sleeping on lying down 10. Insufficient access for dental care resulting in multiple decayed teeth 11.Misaligned teeth because of lack of space for the eruption of the normal component of teeth 12.Other emotional, social and psychological disturbances.