temporomandibular joint:

etiology, pathogenesis,
classification, clinical
features, diagnosis and
treatment of ankylosis.
Contracture of the mandible:
etiology, classification,
clinical features, differential
diagnosis, treatment,
prevention. Dislocations
mandible: etiology,

Temporomandibular joint,
(TMJ), an essential joint of the face, required for speech and
nutrition; a synovial joint formed by the mandibular fossa of
the temporal bone and the head of the condyle of the
mandible with an intervening articular disc. The joint surface
is completely covered by a thick fibrous capsule that allows
for range of movements.

Ankylosis (joint stiffness)

is the pathological fusion of parts of a joint resulting in
restricted movement across the joint

Ankylosis of the Temporomandibular joint, an

arthrogenic disorder of the TMJ, refers to restricted
mandibular movements (hypomobility) with deviation to the
affected side on opening of the mouth.

Affects all age group but more in the first

decade of life (0 10 years)

Theres equal male and female distribution
Almost all cases are unilateral.

Trauma
-At birth (with forceps)
-Blow to the chin (causing
haemarthrosis)
-Condylar fracture

Systemic disease
-Small pox
-Ankylosing spondylitis
-Syphilis
-Typhoid fever
-Scarlet fever

Infections and Inflammatory

-Rheumatoid Arthritis
-Septic arthritis
-Otitis media
-Mastoditis
-Parotitis
-Osteomyelitis
-Osteoarthritis
-Tonsillitis

Others
-Malignancies
-Post radiology
-Post surgery
-Prolonged trismus

TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space

Intra-capsular ankylosis

Extra-capsular ankylosis

Intra-capsular ankylosis
Theres destruction of the

meniscus and flattening of the

temporal fossa
thickening and flattening of the

condylar head and a narrowing of

the joint space.
Opposing surfaces then develop

fibrous adhesions that inhibit

normal movements and finally, may
become ossified.

Extra-capsular ankylosis
Theres an external fibrous

encapsulation with minimal

destruction of the joint
itself.

Inability to open the jaws

In unilateral ankylosis, the lower jaws shifts towards the affected

side on opening of the mouth

In severe cases, there is complete immobilization
There may be Abnormal forward protrusion of the mandible as
the excess tissues occupies the space
Facial deformity
Others are related to the underlying cause of the ankylosis
Fever
Pain
Other bones and joints deformities

Fibrous Ankylosis

Bony ankylosis

Produced by adhesions within the TMJ affecting

the fibrous components

The union of bones of the TMJ by proliferation

bone cells, resulting in immobility of the joint

Not usually associated with pain

Limited range of motion on

opening

pain

Deviated to the affected side

Limited laterotrusion to the

More marked limitation on

opening

contralateral side
No radiographic findings other

Not usually associated with

Theres more marked

ipsilateral deviation

Theres more marked

that absence of ipsilateral

limitation of contralateral

condylar translation

lateral movment

Theres a radiographic
evidence of bone
proliferation

Speech impairment
Facial growth distortion
Nutritional impairment
Respiratory disorders
Malocclusion
Poor oral hygiene
Multiple carious and impacted

teeth

 Non

surgical

management
Surgical treatment

Aims and Objectives of surgery

To release ankylosed mass and creation of a gap to mobilize

the joint
Creation of functional joint (improve patients oral hygiene,

nutrition and good speech)

To reconstruct the joint and restore the vertical height of the

ramus
To prevent re-occurrence
To restore normal facial growth pattern
To improve esthetic appearance of the face (cosmetic reason)
Physiotherapy follow-up

Procedures
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty

CONDYLECTOMY
This procedure is usually indicated when the joint space is obliterated
with the deposition of fibrous bands; but, there hasnt been much
deformity of the condylar head. Usually employed in cases of fibrous
ankylosis.
Pre-auricular incision is made
Horizontal cut carried is out at the level of the condylar neck
The head (condyle) should be separated from the superior attachment
carefully
The wound is then sutured in layers
The usual complication of this procedure is an ipsilateral deviation to
the affected side. And anterior open bite if the procedure was
bilaterally.

GAP ARTHROPLASTY
This procedure is employed in an extensive bony ankylosis.
The section here consists of two horizontal osteotomy cuts
And removal of bony wedges for creation of a gap between
the roof of the glenoid fossa and the ramus of the mandible.
This gap permits mobility
The minimum gap should be 1cm to avoid re-ankylosis

INTERPOSITIONAL ARTHROPLASTY

This is actually an improvement/modification on gap

arthroplasty
Currently the surgical protocol of choice
Materials are used to interpose between the ramus of the
mandible and base of the skull to avoid re-ankylosis
The procedure involves the creation of gap, but in addition, a
barrier is inserted between the two surfaces to avoid
reoccurrence and to maintain the vertical height of the ramus

INTERPOSITIONAL ARTHROPLASTY

MATERIALS USED IN INTERPOSITIONAL

ARTHROPLASTY
Autogenous

Heterogenous

Alloplastic

I.

I.

chromatised
submucosa of pigs
bladder

Metallic: tantalum foil

and plate, 316L
stainless steel,
Titanium, Gold.

II.

lyophilized bovine
cartilage

Nonmetallic: silastic,
Teflon, acrylic, nylon,
ceramic

Temporalis muscles

II. Temporalis fascia

III. Fascia lata
IV. Cartiligenous grafts
Costochondral
Metatartsal
Sternoclavicular
Auricular graft
V. Dermis

Advantages of this procedure

(interpositional arthroplasty)

Autografts, such as skin, temporalis muscle, or fascia lata, are

presently considered the material of choice for interposition.
In more recent years, a pedicled temporalis myofascial or
temporalis fascia flap has been advocated in TMJ surgery to treat
the TMJ ankylosis.
Advantages of these flaps in TMJ reconstruction include
close proximity to the TMJ without involving an additional
surgical site,

adequate blood supply,

autogenous origin grafts can be used,

and maintenance of attachment to the coronoid process,
which provides movement of the flap during function,
simulating physiologic action of the disc.

Advantages of this procedure

Post -OP

(interpositional arthroplasty)

Complications of the surgery

Anaesthesia
Aspiration of blood clot, tooth or foreign body
Falling back of the tongue causing airway obstruction
Intra-Operative
Haemorrhage (damage of any superficial temporal vessels, transverse
facial artery, etc)
Damage to the external auditory meatus
Damage to the Zygomatic and temp. branch of facial nerve
Damage to the Glenoid fossa
Damage to the Auriculotemporal nerve
Damage to the Parotid gland
Damage to the teeth
Post Operative
infection
open bite
re-occurrence of ankylosis

A restricted ability of the

lower jaw to move is
designated as contracture.

Forms of contracture:
Inflammatory contracture
Muscular contracture
Arthrogenous contracture
Fibrous contracture
Neurogenic contracture

Intra-Articular Causes
Ankylosis

Arthiritis Synovitis
Meniscus Pathology

Extra-Articular Causes
Infection:
Odontogenic- Pulpal
Periodontal
Pericoronal
Non-Odontogenic- Peritonsillar abscess
Tetanus
Meningitis
Brain abscess
Parotid abscess

Trauma
Fractures, particularly those of the mandible
and Fractures of zygomatic arch and zygomatic
arch complex,Accidental incorporation of foreign
bodies due to external traumatic injury
Treatment: fracture reduction, removal of foreign
bodies with antibiotic coverage
TMJ Disorders
Extra-capsular disorders Myofascial Pain
Dysfunction Syndrome
Intra-capsular problems Disc Displacement,
Arthritis, Fibrosis, .. etc.
Acute closed locked conditions displaced
meniscus

Tumors and Oral care

Rarely, trismus is a symptom of
nasopharyngeal or infratemporal tumors/
fibrosis of temporalis tendon, when patient has
limited mouth opening, always premalignant
conditions like oral submucous fibrosis (OSMF)
should also be considered in differential
diagnosis.
Drug Therapy
Succinyl choline, phenothiazines and tricyclic
antidepressants causes trismus as a secondary
effect. Trismus can be seen as an extrapyramidal side-effect of metaclopromide,
phenothiazines and other medications.

Radiotherapy and Chemotherapy

Complications of Radiotherapy:
Osteoradionecrosis may result in pain,
trismus, suppuration and occasionally a foul
smelling wound.
When muscles of mastication are within the
field of radiation, it leads to fibrosis and result in
decreased mouth opening.
Complications of Chemotherapy:
Oral mucosal cells have high growth rate and
are susceptible to the toxic effects of
chemotherapy, which lead to stomatitis.

Congenital / Developmental Causes

Hypertrophy of coronoid process causes
interference of coronoid against the
anteromedial margin of the zygomatic arch.
Trismus-pseudo-camtodactyly syndrome is a
rare combination of hand, foot and mouth
abnormalities and trismus.
Miscellaneous disorders
Hysteric patients: Through the mechanisms of
conversion, the emotional conflict are
converted into a physical symptom. E.g.:
trismus
Scleroderma: A condition marked by edema
and induration of the skin involving facial region
can cause trismus

Common causes
Lock-jaw caused due to muscle rigidity.
Pericoronitis (inflammation of soft tissue around impacted third molar)
is the most common cause of trismus.
Inflammation of muscles of mastication. It is a frequent sequel to
surgical removal of mandibular third molars (lower wisdom teeth). The
condition is usually resolved on its own in 1014 days, during which
time eating and oral hygiene are compromised. The application of heat
(e.g. heat bag extraorally, and warm salt water intraorally) may help,
reducing the severity and duration of the condition.
Peritonsillar abscess, a complication of tonsillitis which usually presents
with sore throat, dysphagia, fever, and change in voice.
Temporomandibular joint dysfunction (TMD).[8]
Trismus is often mistaken as a common temporary side effect of many
stimulants of the sympathetic nervous system. Users of amphetamines
as well as many other pharmacological agents commonly report
bruxism as a side-effect; however, it is sometimes mis-referred to as
trismus. Users' jaws do not lock, but rather the muscles become tight
and the jaw clenched. It is still perfectly possible to open the mouth.[8]
Submucous fibrosis.

Lock-jaw caused due to

muscle rigidity.

Dislocation
Dislocation is a complete
separation of the articular
surfaces with fixation in an
abnormal position.

Anterior dislocation of the

condyle in which the normal
anatomic relationships within
the joint have been completely
disrupted occurs with the

mandibular dislocation -- the

condyle (c) is anterior to the
articular eminence (e)

Causes:
Deep yawning
Prolong Dental procedures
Airway manipulation particularly in an
anaesthetised patient.
Dislocation can occur during laryngoscopy,
transoral fiberoptic bronchoscopy and
intubation.

Clinical
features:
TMJ dislocation may occur with trauma, but most
often follows extreme opening of the mouth
during yawning, laughing, singing, vomiting, or
dental treatment .
Dislocation also can result from dystonic reactions
to drugs .
Symmetric mandibular dislocation is most
common, but unilateral dislocation with the jaw
deviating to the opposite side also can occur.
TMJ dislocation is painful and frightening for the
patient.

On
examination
:

The patient is unable to close the mouth and there is

excessive salivation .
A depression may be noted in the preauricular area.
Palpation of the TMJ reveals one or both of the condyles
trapped in front of the articular eminence and spasm of the
muscles of mastication.
Patients prone to mandibular dislocation include those
with an anatomic mismatch between the fossae and
articular eminence, weakness of the capsule and the
temporomandibular ligaments, and torn ligaments.
Patients who have had one episode of dislocation are
predisposed to recurrence .

Diagnosis:
The dentist bases the diagnosis on the position
of the jaw and the person's inability to close his
or her mouth.
Radiographs of the TMJ are not always
necessary, but should be obtained to exclude
condylar fracture if the dislocation is related to
trauma
The problem remains until the joint is moved
back into place. However, the area can be tender
for a few days.

Treatment :
The muscles surrounding the temporomandibular joint
need to relax so that the condyle can return to its normal
position.
Many people can have their dislocated jaw corrected
without local anesthetics or muscled relaxants. However,
some people need an injection of local anesthesia in the
jaw joint, followed by a muscle relaxant to relax the
spasms.
The muscle relaxant is given intravenously (into a vein in
the arm). Rarely, someone may need a general anesthetic
in the operating room to have the dislocation corrected.
In this case, it may be necessary to wire the jaws shut or
use elastics between the top and bottom teeth to limit the
movement of the jaw.

 To move the condyle back into the correct position,

a doctor or dentist will pull the lower jaw downward
and tip the chin upward to free the condyle .
The doctor or dentist then guides the ball back into
the socket.
After the joint is relocated, a soft or liquid diet is
recommended for several days to minimize jaw
movement and stress.
People should avoid foods that are hard to chew,
such as tough meats, carrots, hard candies or ice
cubes, and advice not to open their mouths too
widely.

 TMJ dislocation can continue to happen in people with

Prevention:
loose TMJ ligaments. To keep this from happening too
often, dentists recommend that people limit the range of
motion of their jaws, for example by placing their fist
under their chin when they yawn to keep from opening
their mouths too widely.
Conservative surgical treatments can help to prevent the
problem from returning.
Some people have their jaws are wired shut for a period
of time, which causes the ligaments to become less
flexible and restricts their movement.
In certain cases, surgery may be necessary.
Eminectomy removal of the articular eminence so that
the ball of the joint no longer gets stuck in front of it.
Another procedure involves injecting medications into
the TMJ ligaments to tighten them.

Prognosis:
The outlook is excellent for returning the
dislocated ball of the joint to the socket.
However, in some people, the joint may continue
to become dislocated , If this happens, needs
surgery.