TMJ Ankylosis

from Kazanjian to Kaban......

- Dr Jawfixer
INTRODUCTION
• Temporomandibular joint (TMJ) ankylosis- bony
or fibrous adhesion of the anatomic joint components
accompanied by limitation of mouth opening, causing
difficulty in mastication, speech, and oral hygiene.
• Affects symmetry of the facial skeleton, especially in
cases which occur when patient is still in the growth
phase.
Etiology and pathogenesis
Kaban
• Trauma (31-98%)- heamarthrosis following trauma
• Infections (10-40%)- otitis media, scarlet fever, TB
• Systemic diseases (10%)- AS, RA, psoriasis
• Post op surgical complication
• Restricted jaw movement is not a determinant but rather a
promoting agent for ankylosis.
• Injuries to both the articular disc and the articular
surfaces are prerequisites to TMJ ankylosis.

Kaban LB, Perrott DH, Fisher K. A protocol for management of

temporomandibular joint ankylosis. J Oral Maxillofac Surg.
1990;48:1145–51
Yan et al. (2014) hypotheses of hypertrophic
nonunion
• He described the sagittal fracture of condyle along
with displacement of the disc. Trauma also occurs in
the glenoid fossa, thereby establishing the
microenvironment in the articular surfaces for bone
healing.
Trauma:
• Medially displaced condylar fracture
• Intracapsular fracture
• Birth trauma- forceps delivery
Medially displaced condylar fracture
Medially displaced condylar fracture
• Fracture of condyle – sagittal
intracapsular
• Associated fracture of anterior mandible
• No/inadequate reduction leading to
increase in bigonial width and flaring of
ramus
• The raw lateral segment of fracture
displaced laterally and superiorly
contacting the glenoid fossa
• Hypomobility – pain,other systemic
conditions,MMF(iatrogenic)
• In 61 patients- 93% has a medially displaced non
ankylosed condylar head.
• All post traumatic ankylosis were juxta articular
• Intra articular ankylosis were either recurrent or post
infective
• Early arthroplasty – do not hamper growth – remodelling
was enhanced
• One case was treated early and ankylosis was prevented
• Second case presented with ankylosis
Intracapsular fractures
Intracapsular fractures- condylar burst hypothesis
• Condylar head in younger person is not well developed
with wide neck and soft head
• Less adapted to crushing injuries directed along its long
axis
• Leads to burst condyle
• Intracapsular hematoma and bone fragments

Row NL. Ankylosis of the temporomandibular joint. Part 3. J

R Coll Surg Edinb 1982: 27: 209-18
Intracapsular hematoma?
Intracapsular hematoma?
• Otzan et al proved that Intracapsular hematoma
formation is not enough for ankylosis formation
• Collection of blood , bone , cartilage fragments leads to
environment favoring ankylosis
Importance of meniscus...
• Contact between articular surface of glenoid fossa and ramus
was essential for ankylosis*
• Young Patients
higher osteogenic potential + rapid repair
Anatomical differences
Low pain threshold , prolonged self imposed immobilization
Higher proportion of bilateral condylar fractures with chances of
communition
More frequent medial displacement of condylar head
Greater potential of glenoid fossa fracture
Laskin DM. Role of the meniscus in the etiology of posttraumatic
temporomandibular joint ankylosis. Int J Oral Surg 1978;7:340–5
Importance of meniscus...
• Severity of trauma – extend of damage to TMJ
• Site of fracture- intracapsular fractures
• Duration of immobilisation- experimental studies showed
no conclusive evidence but clinical experiences tells
otherwise
• Damage to disc – direct contact between the condyle and
fossa

Laskin DM. Role of the meniscus in the etiology of posttraumatic

temporomandibular joint ankylosis. Int J Oral Surg 1978;7:340–5
Intracapsular fractures
• The disease course is similar to hypetrophic bone non
union .
• Arthrodesis- in sheeps
• Fibrous ankylosis – atrophic non union
Dual effect of mouth
opening on new bone
formation in recent
condylar trauma
Intracapsular fracture- extracapsular
hematoma
Surgical
• Tmj surgeries- violating the anatomic boundaries,
creating hematoma in the joints
Surgical – orthognathic surgery
Classification
Kazanjian -1938
• True ankylosis – pathology lies in the joint
proper- intra articular
• False ankylosis – pathology lies outside
the joint – extrarticular
• Complete ankylosis – mouth opening
<5mm
• Partial ankylosis
• Bony ankylosis
• Fibrosis ankylosis
Topazian- 1966
• Stage I – ankylotic mass limited to
condyle process
• Stage II- ankylotic mass extending to the
sigmoid notch
• Stage III- ankylotic mass extending to the
coronoid process
 C P Sawhney- 1986
Based on radiographic and
operative findings
• Type I
1. the head is flattened/
deformed
2. lay closely
approximated to upper
articular surface
3. Dense fibrous adhesions
4. Following comminuted
head fracture
 C P Sawhney- 1986
• Type II
1. Head is
mishaped/flattened
2. Bony fusion of head to
outer edge of articular
surface but limited to a
small area
3. Upper articular surface
and disk undamaged
deeper to bony fusion
4. Severe comminuted head
fracture with partial
damage to upper articular
surface
 C P Sawhney- 1986

• Type III
1. bony block bridging
between the ramus and
zygomatic arch
2. Upper articular surface and
disc on deeper aspect
intact
3. fracture dislocation of
head and neck of condyle
and laceration of capsular
ligaments
4. The head is atrophic, found
medially
 C P Sawhney- 1986

• Type IV
1. bony block is wide and
deep ,completely
obliterating the joint
architecture
2. fracture dislocation of
head and neck of condyle
and laceration of capsular
ligaments, injury to upper
articular surface
3. Most common
presentation
El-Hakim and SA Metwalli-2002
• Based on findings in post contract coronal CT
1. Class I- fibrous ankylosis
2. Class II- bony ankylosis
3. classIII- the distance between maxillary
artery and medial pole of condyle less on the
ankylosed side/maxillary artery lies within
the bony ankylotic mass (coronal CT)
4. Class IV- ankylotic mass fused to the base of
the skull, close approximation with pterygoid
plates,carotid and jugular foramina,foramen
spinosum (axial CT)
El-Hakim and SA Metwalli-2002
El-Hakim and SA Metwalli-2002
 Dongmei He- 2010
• Based on coronal CT scans
Type A1 – fibrous ankylosis
Type A2 – ankylosis with bony
fusion on lateral side of joint
, residual condylar fragment
is bigger than 0.5 of
condylar head in the medial
side
 Dongmei He- 2010

Type A3- residual condylar

fragment is smaller than 0.5 of
the normal condyle
Type A4- complete bony
ankylosis of joint
Clinical features
Clinical features
• Decreased inter-incisal opening < 5 mm
• Inability to form oral seal
• Absent condylar movements
• Restricted mandibular growth
• Hyperactive mentalis
• Iip trap/lip incompetence
• Prominent antegonial notch
• Malocclusion
• Poor oral hygiene
• OSA/day time sleepiness/ respiratory difficulty
Clinical features- unilateral
• Chin deviation
towards affected
side
• Fullness on affected
side ,
• flattening on
contralateral side
• Shortened vertical
height of ramu
• Deepened
antegonial notch
Clinical features- bilateral
• Retrognathic mandible
• Microgenia
• Bird facies deformity
• Convex profile
• Short hyomental
distance
• Tight suprahyoid
musculature
• Absent / deficient
cervico-mental angle
• Open bite
• B/L posterior crossbite
Radiographic features
Panorex
Lateral ceph
PA ceph
CT scans
Panorex
Lateral cephalogram
• Shortened posterior
facial height
• Steep occlusal and
mandibular planes
• Retrognathia
• Retrogenia
• Airway narrowing
PA cephalogram
• To evaluate chin deviation
• Facial deformity
• Occlusal cant
CT scan
• To be reviewed in saggital, coronal and
axial section to determine the
mediolateral + anteroposterior extent
along with proximity with skull base and
external auditory canal
 Coronal sections
• Mushroom shaped head
• Mediolateral extent and level of
inferior cut
• Proximity to maxillary artery
• Level of lingula
• Proximity to lateral pterygoid plate
• Radiolucent area inside the
ankylotic mass , represents disk
 VRT images
• Elongated coronoid process
• shallow sigmoid notch
• Reduced vertical height
• Accentuated antegonial notch
• Mandibular asymmetry
When is coronoid enlarged?
Kr-go/cd-go
is
• <1.07 –
normal
• 1.07-1.15-
borderline
• >1.o5 –
hyperplasi
a
Why is the coronoid enlarged in TMJ
ankylosis??
• “ restriction in range of mouth opening
and persist efforts by the depressors on
the mandible produces marked notching
in the lower border of mandible just in
front of the insertion of masseter and
medial pterygoid”
Why is the coronoid enlarged in TMJ
ankylosis??
• Concept of reciprocal inhibition
• Reduced mouth opening- reduced masticatory
efficancy- greater number of chewing cycles
• Predominant motion- end closure- anterior fibers
of masseter
• Temporalis and masseter is in a state of
myostatic contracture – when complete
relaxation of muscle is prevented
• Tendon – avascular – stiffening and fibrosis
Why is the coronoid enlarged in TMJ
ankylosis??
• Increased activity of anterior fibers of
temporalis – load related bone growth/
physiologic distraction osteogenesis
• Loss of reciprocal inhibition –
contractions of both elevators and
depressors – fulcrum
Management
Primary treatment goals
• Resection of ankylosis and achieve normal mouth opening

• Restoration of function of TMJ

• Prevent reankylosis

• Achieve symmetric mandibular / correct mandibular

asymmetry
Surgical treatment outcomes

• Children – functional and growth

• Adults – functional and aesthetic

Challenges
Anesthetic challenges
• Difficult intubation due to inability to open mouth
and altered upper airway anatomy. Can be
overcome by
• Blind nasoendotracheal intubation
• Awake fibreoptic assisted nasoendotracheal
intubation
• Tracheostomy

• Desaturation – perioperative / post extubation

• Extreme sensitivity to all central nervous system

depressants
Challenges
• Restoration of growth centre/return to normal growth

• Correction of esthetics

• Reankylosis
Surgical approaches
• Pre-auricular
• Preauricular- hockey stick
• Al-kayat Bramley modification of pre-auricular
• Endaural
• Post-auricular
• Submandibular
• Rhytidectomy
• Intraoral
Treatment options
• Lateral arthroplasty
• Gap arthroplasty
• Interposition arthroplasty
• Reconstructive arthroplasty
 Lateral arthroplasty?
• Resection of lateral bony fusion and
preservation of the medial condyle and
disc
• TMF is sutured to the lateral aspect of
the disc
• Also called as condyle preserving
arthroplasty
• Advocated mostly in chineese literature
• The medial condyle should be >0.5
times the normal condyle
Lateral arthroplasty
Advantage lies in the preservation of the physiology joint
along with disc, preventing reduction in ramal height
Limitations
• 36.4% recurrence (4 out of 11 patients)
• Leaving behind the medial aspect of ankylosis?
Gap arthroplasty
• Resection of the osseous mass between the articular cavity
and the mandibular ramus.
Advantages:
• Restores function , facial remodeling follows
• Relies on functional matrix theory of Moss and salantijin
• Excellent in terms of prevention of recurrence
• Simple operation
• No donor site morbidity
Gap arthroplasty
Disadvantages
• Ramal shortening
• Precipitant OSAS
• Anterior open bite
• High recurrence according to some authors
• No restoration of growth center so aggravation of facial
deformity over time
Interposition 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).
Interposition materials
Autogeneous
Buccal fat pad
Abdominal fat pad
Temporalis myofascial flap
Fascia Lata
Dermis
Auricular cartilage
Interposition materials
Alloplastic
Metallic
Tantalum foil/plate
Stainless steel
Non-metallic
Silastic
teflon
Acrylic
Nylon
Temporalis Myofascial Flap(TMP)
• First used by Blair and Murphy in 1914 for interpostional
arthoplasty.
Advantages:
Autogenous nature
Adequate blood supply
Proximity to the joint, allowing for a pedicled transfer of vascularized tissue
into the joint area
Surgical technique
Complications
• Flap Necrosis :- Incidence Less than 2 %;
• Temporal Hollowing
• Facial Nerve injury
Modification
• Fascia facing both
surfaces
• Increased bulk
• Less open bite
• Less chance of temporalis
muscle degeneration
Long term viability of temporalis
muscle flap
• Based on MRI and surgical findings and
histological findings
• TF do survive when its carefully dissected
and inferiorly based to preserve its blood
supply
Buccal fat pad
Advantages
Autogenous nature
Proximity to the surgical defect
Have blood supply through its pedicle
Technique
• After Osteo-arthectomy and ipsilateral
coronoidectomy, blunt subperiosteal dissection
in the direction of coronoid process is carried
out with a small hemostat.

• Buccal fat pad can be identified by its yellow

color, then it can be gently pulled out in the
defect with two hemostat, along with
simultaneous milking in maxillary buccal sulcus
intra-orally near second molar
Long term fate of BFP
Dermis fat interposition
• 11 temporomandibular joint ankylosis
adult patients. All patients underwent gap
arthoplasty and resultant gap was filled
with autologous dermal fat harvesting
from groin region.
• The study concluded that use of
autologous dermal fat graft is effective for
prevention of reankylosis upto 6 years
following surgical release of ankylosis of
temporomandibular joint
Fascia lata interposition
• Zhou, et all in 2002: In 7 patients with TMJ ankylosis
treated with autologous auricular cartilage graft
interposition arthroplasty, the function of the TMJ
recovered well.
• At 6-year follow-up, no relapse had occurred and no
deformities resulted in the ear from which the cartilage
had been harvested.
Interposition using acrylic
• interpositional arthoplasty using acrylic
cylinder in bony ankylosis of
temporomandibular joint ankylosis in 70
patients followed by trauma.
• Surgical treatment was done by creating
elliptical gap between two bony surfaces
by neurosurgical bur, perforater and
chisel
Comparison
• IPG better than GA in terms of recurrence
and MIO
• IPG greater MIO and comparable
recurrence with CCG
• CCg greater MIO compared to AJR
• AJR superior to CCG in reducing pain
Kaban’s protocol
1. Removal of the ankylotic chunk to create a gap of not
less than 1.5 cm
2. Ipsilateral coronoidectomy. After this resection is
completed, the MIO is measured. Should be > 35 mm
passive or in unilateral cases , till translocation of
contralateral condyle
3. Contralateral coronoidectomy.
4. Temporalis fascia flap and costochondral graft harvest.
5. Rigid fixation of CCG
6. MMF in prefabricated splint x 10 days
7. Release of MMF and a strict protocol of physiotherapy
with therabite appliance is employed.
Kaban protocol modified...
1. Aggressive excision of fibrous / bony mass
2. Coronoidectomy on ipsilateral side
3. Coronoidectomy on opposite side if step 1 and 2 do not
result in MIO of > 35 mm or dislocation of opposite side
4. Lining of joint with temporalis fascia or native disc
5. Reconstruction of Ramus-Condylar Unit with Distraction
Osteogensis or Costo-Chondral Graft and rigid fixation
6. Early mobilization
7. Aggressive physiotherapy
What changed from 1990 to
2009
• Introduction of DO
• Fixation of CCG – two or three 2.7mm
screws
to 2mm miniplate and three
screws(washer)
• Preauricular with extension – hemicoronal
• Bell dynamic jaw exerciser to therabite
appliance
• Importance of fourth dimension (time and
growth) on the outcome
What changed from 1990 to 2009
• In 6 weeks follow up – MIO
• Timing of treatment – should be done as early as possible
– children 3 years or older.
• Thickness of TMF- atleast 4mm
How much mouth opening should be achieved??
• Optimal interincisal opening – 35 -50mm with enough
translation to produce normal translation of opposite
condyle