SURGICAL APPROACHES TO

TEMPOROMANDIBULAR JOINT
Surgical access to the temporomandibular joint is an exacting procedure. It requires technical
skill and a thorough knowledge of anatomy of the area. Several approaches to the TMJ have been
proposed and used clinically. The sugical approaches are as follows.

 Submandibular approach
 Postramal approach
 Post auricular approach
 Pre auricular approach
 Hemi coronal approach
 Coronal approach
 Endaural approa

The basic technique for surgical correction of ankylosis includes –

 Condylectony
 Gap arthroplasty.
 Joint reconstruction or Interpositional arthroplasty.

Most surgical procedures can be done through a preauricular incision alone. The Popowich’s
incision is the most preferable for its obvious advantages. Whenever required, additional
submandibular incision can be used for fixation of the graft.

SURGICAL TECHNIQUE
The ideal surgical technique perform for the temporomandibular joint ankylosis is Condylectomy
with interpositional gap arthroplasty.
Procedure
This surgery is performed under general anesthesia with naso-tracheal intubation. Intubation
creates problem in children with bird face appearances so blind intubation is preferred. The
method of blind intubation in the conscious patient is done with the tube being passed after the
nose has been sprayed with cocain, further cocainization of the pharynx and larynx being
achieved via the tube itself once the tube is in place, the operation can be performed under gas-
and-oxygen anaesthesia,and the tube left in situ until the patient is again fully conscious. Access
to the joint is made for which variety of incision are recommended but preauricular approach is
the most accepted approach in this case . Popowich's incision which is the modification of
Preauricular incision Here the upper part of the incision is extended in a question mark(?)
fashion over the temporal area to give better access. Osteotomy is carried out with the help of the
surgical bur at the level of condylar neck.Vital structure on the medial surface of the condylar
neck should be protected by using special condylar retractor, inserted prior to the bony cut. The
condylar head then should be separated from the superior attachment carefully. Then create a gap
of at least 1 to 2 cm .A gap was created by removing the fibrous osseous tissue and bone is
removed by using a large round bur, until the medial bone is thinned out enough to be readily
removed by hand chisel or osteotome .It is important to create a gap of equal dimension both
laterally and medially, so that the possibility of medial reankylosis due to
bone contact is avoided . After creation of the gap a barrier( Autogenous or Alloplastic) material
is inserted between the cut bony surfaces to minimize the risk of recurrence and to maintain the
vertical height of the ramus.
INTERPOSITIONAL MATERIALS
The interpositional materials used in the surgery of temporomandibular joint ankylosis are:
Autogenous material
 Cartilaginous grafts
 Temporalis muscle
 Temporalis fascia
 Fascia lata
 Dermis
Alloplastic material

Metallic
 Tantalum foil/plate
 Stainless steel
 Gold
 Titanium
Non metallic
 Silastic
 Teflon
 Acrylic
 Ceramic implant
 INTERPOSITION ARTHROPLASTY USING
AUTOGENOUS COSTOCHONDRAL GRAFT
Now a day's Costochondral graft interposition arthroplasty is the most accepted method for the
treatment of Temporomandibular Joint ankylosis. This was the mainstay of the Rx of ankylosis
for more than 100 years.

Goals
The goals of use of Autogenous Costochondral grafts are :

1. To replicate structurally normal joint anatomy.

2. To provide functional articulation.
3. To established an area where adoptive growth can occur in children.

Advantage:
The advantages of costochondral grafts are as follows:
 Costochondral graft contains a cartilaginous part which helps in maintain the normal
architecture of temporomandibular joint.
 Costochondral graft includes biologic and anatomic similarity to the mandibular condyle.
 Ease in obtaining and adopting the graft.
 Increase mouth opening.
 Low morbidity.
 Re-generation of donor sites & a demonstrated growth potential in juvenile recipients.

Disadvantage:
The disadvantage of Autogenous Costochondral grafts are :
 Increased operating time.
 Additional surgical site.
 Possible potential for reankylosis.
 Donor site morbidity- such as pneumothorax, pleuritic pain.
 Numb lower lip.
 Complication at both donor & recipient sites.
 Occlusal change.
 Pain, infection and uncontrolled and unpredictable growth.
 LINING OF THE GLENOID FOSSA SIDE BY
TEMPORALIS MYOFASCIAL FLAP
Temporalis muscle and fascia, as an axial pedicled flap has been used to provide soft tissue lining
for TMJ reconstruction. In addition, the flap has been used as an inter positional tissue for the gap
arthroplasty procedure for ankylosis. The temporalis flap is commonly based inferiorly on the deep
temporal artery and rotated over the zygomatic arch into the joint, with the muscle facing the
condylar surface. Other investigators describe anteriorly and inferiorly based temporalis myofacial
flap rotated beneath the zygomatic arch and also positioned so that the fascia lines the glenoid
fossa and the muscle faces the condyle. Still others recommend that the flap be posteriorly based
and passed under the arch. As the vascular supply and the nerves enter the muscle and fascia from
an inferior, medial and posterior direction, these anatomic relationships support the use of inferior
and posterior based flaps. The principal advantages of the temporalis muscle and fascia flap are
their autogenous nature, resilience and adequate blood supply, close proximity to the site.

THE INTERNATIONALLY ACCEPTED PROTOCOLS

FOR THE MANAGEMENT OF TMJ ANKYLOSIS
The internationally accepted protocols are:

 Early surgical intervention.

 A gap of at least 1 to 1.5 cm should be created.
 Ipsilateral coronoidectomy and temporalis myotomy.
 Contra lateral coronoidectomy and temporalis myotomy is necessary.
 Lining of the glenoid fossa region with temporalis fascia.
 Reconstruction of the ramus with Costochondral graft.
 Rigid fixation of the graft.
 Early mobilization and physiotherapy for at least six month postoperatively.
 Regular long term follow up.
 Cosmetic surgery later.

COMPLICATION
The complications of temporomandibular ankylosis before and after the surgery are:

During anesthesia
 As the patient can't open the mouth, awake blind intubation has to be done where
patient co operation is required which is very difficult to obtain from younger group of
patient.
  Because of small mandible and altered position of the larynx, intubation poses a
problem.
 Aspiration of blood clot, tooth or foreign body during extubation as throat can't be
packed prior to surgery.
 Danger of falling back of tongue.

During surgery

 Hemorrhage.
 Damage to auditory meatus.
 Damage to zygomatic and temporal branch of facial nerve.
 Damage to glenoid fossa.
 Damage to auriculotemporal nerve.
 Damage to parotid gland.
 Damage to the teeth during opening of the jaw with jaw stretcher.
 Frey's syndrome
Post operative
 Infection.
 Open bite.
 Recurrence of ankylosis.

Frey's Syndrome
It is the incidence, of localized gustatory sweating and flushing, following gun shot wound and
suppurative parotitis or any surgery in the pre- auricular region. It is also known as
auriculotemporal nerve syndrome.

1. It is characterized by pain in the auriculotemporal nerve distribution.

2. Associated gustatory sweating and occasionally erythema is seen
3. There is flushing on the affected side of the face accompanied by sweating within the
hairline, the peri-auricular region and beneath the pinna on eating or starring at food or
thinking of any delicious food.
4. A minor starch iodine test is positive in these patients.

RECURRENCE OF TMJ ANKYLOSIS

Recurrence of TMJ ankylosis is distressing both to the patient and surgeon.
Factors responsible for reankylosis are:
 An inadequate gap created between the fragments.
  Missing of the medial condylar stump and leaving it behind.
 Fracture of the Costochondral graft.
 Loosening of the Costochondral graft due to inadequate fixation to the ramus.
 Inadequate coverage of the glenoid fossa surface.
 Inadequate post operative physiotherapy.
 Higher osteogenic potential and periosteal osteogenic power may be responsible for
high rate of recurrence in children.
 The use of alloplastic material causes higher risk of foreign body granuloma and favor
ankylosis relapse and hinder rehabilitation.

PREVENTION OF RECURRENCE
 Inter positioning of the TMJ with temporal fascia or cartilage may be done to prevent
re ankylosis of the joint
 Therapeutic treatment (biphosphonates, NSAIDS) and physiotherapy discourage
reankylosis of the joint after surgical correction.
 Jaw opening exercise must be performed for months to years to maintain the normal
mouth opening.
 Silastic as alloplastic material could not be used as an inter positional material.
Correction of Facial Deformity
Facial deformity and asymmetry can be corrected by distraction osteogenesis, orthognathic
surgery- genioplasty or extended sliding genioplasty, saggital split osteotomy.

Distraction Osteogenesis: It is the process of generating new bone by the slow stretching of callus
in a gap between two bone segments in response to the application of graduated tensile stress
across the bone gap. That means bone can regenerate itself without the use of bone grafts or
growth promoting factors. It is generally performed in the growing period.

Genioplasty: For the correction of the facial deformity Augmentation genioplasty is used to
increase the chin projection. It can be done by:

• Sliding horizontal osteotomy of the synphysis region.

• Using autogenous bone graft.
• Using alloplastic material- silastic, hydroxyapatite etc.

Saggital Split Osteotomy: This procedure is performed on the mandibuler ramus and body. This
is accomplished through transoral incision. The osteotomy splits the ramus ansd the posterior
bosdy of the mandible sagittally, which allows either setback or advancement.
CONCLUSION
Reconstruction of the temporomandibular articulation is one of the most demanding challenges in
maxillo facial surgery. Diagnosis and treatment of this oral manifestation is complex, involving
several health practitioners such as physicians, dental surgeons, physiotherapists and
psychologists. Early surgery can minimize the severity of the restriction of facial growth.

REFERENCES
1) Text book of Oral and Maxillofacial Surgery by Neelima Anil Malik
2) Contemporary Oral and Maxillofacial surgery (4th Edition) by Peterson, Ellis, Hupp, Tucker
3) Text book of Oral and Maxillofacial surgery (2nd Edition) by Vinod Kapoor

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