TMJ Disorders – Symptoms And Causes

TMJ Disorders – Symptoms And Causes

• TMJ ankylosis: There is immobility of the joint, and the jaw function gets affected. Hypomobility to immobility of the joint can lead to inability to open the mouth from partial to complete
• Two main factors predisposing to the ankylosis are trauma and infection, in or around the joint region.

Management of TMJ ankylosis

• Early surface intervention
• Aggressive resection: A gap of at least 1 to 1.5 cm should be created.
• Ipsilateral coronoidectomy and temporalis myotomy.
• Contralateral coronoidectomy and temporalis myotomy.
• The lining of the glenoid fossa region with temporalis fascia.
• Reconstruction of the ramus with costochondral graft.
• Early mobilization and aggression physiotherapy for at least 6 months postoperatively.
• Regular long-term follow-up.
• To carry out cosmetic surgery at a later date when the growth of the patient is complete.

TMJ Principles of Management

• Removal of the ankylosed mass of bone to mobile the jaw.
• Reconstruction of joint and maintenance of vertical height of ramus.
• Prevention of recurrence.
• Restoration of occlusion and maintain function.
• Correction of secondary facial deformity.

Step-by-step treatment of ankylosis

• Use of basement force: Forced opening of the jaw by mouth gag under general anesthesia. It is used in the case of fibrous ankylosis.
• Surgical lysis: Opening of joint by preauricular approach and destroying the union of condyle and glenoid fossa.

• This procedure is done in cases of fibrous or partial ankylosis where the anatomical features of the joint are not completely changed.
• The condylectomy procedure should be started by giving the preauricular incision.
• Now a horizontal osteotomy cut is given with the help of a bur at the level of the condylar neck.
• Section the head of the condyle to the level of the neck and separate it from the superior attachment.
• The stump of the condyle at the neck is smoothened and the wound is closed in layers.
• As unilateral condyle leads to deviation of the mandible at the operated side on mouth opening and in cases of bilateral ankylosis open bite is present due to loss of vertical rami.
• So when condylectomy is done, after recontouring an alloplastic material is used to maintain space and provide proper occlusion as well as joint movements.

• Gap arthroplasty is the procedure that involves the creation of an anatomical gap in an ankylosed segment to form an artificial joint space.
• In patients with complete bony ankylosis anatomical features of joints are very difficult to appreciate as they get covered by the bone. So in complete bony ankylosis cases, a gap in the bone is made to separate the ramus of mandible from the ankylosed mass in the glenoid fossa.
• Now two horizontal bony cuts are given in the superior aspect of the ramus and the wedge of bone between the two cuts is removed. Take care while removing the bone from the medial aspect as it is close to a maxillary artery and carotid canal.
• Remove the bone by using a large round bur till the medial bone gets thinned out completely to remove by osteotome.
• There is a recommendation of leaving a gap of about 1 to 1.5 cm laterally and medially to prevent ankylosis.

• In cases of gap, arthroplasty chances of ankylosis are present, if bony cuts come in contact.
• So to avoid this an interpositional material is inserted in between the two cut ends which avoids contact between them and decreases the chances of ankylosis.
• Various materials are used which can be autogenous or alloplastic.
• Autogenous materials used for interposition are cartilaginous graft, temporal muscle, temporal fascia, fascia, and dermis while alloplastic materials used are metallic and non-metallic.
  In metallic ones, there are tantalum plates, stainless steel, titanium, and gold, and in non-metallic ones, there are Teflon, acrylic, ceramic, and elastic.