TMJ ankylosis is a pathology in which movement in the joint is significantly limited. The disease is usually chronic. The full name of this ailment is ankylosis of the temporomandibular joint. Such a pathology significantly complicates a person’s life. It becomes difficult for the patient to open his mouth, chew food and talk. In addition, pathology affects the appearance, the patient has a pronounced asymmetry of the face. Next, we will consider the causes and diagnosis of TMJ ankylosis, as well as methods of treating this disease.
What is ankylosis
In medicine, ankylosis is the pathology of the articular joint. This is a disease that leads to immobility of the affected area or a violation of normal movements.
TMJ ankylosis is a fusion of the surfaces of the temporomandibular joint. As a result, the gap between the head of the mandibular bone and the fossa of the temporal bone sharply narrows or completely disappears. Due to inflammatory processes, tissues of the articular surfaces melt and adhesions form between them.
The disease develops slowly, the pathological process proceeds for many months and even years. Gradually, the cartilage surfaces of the joints are destroyed. The intraarticular fissure is filled with fibrous or bone tissue.
Causes of the disease
The main cause of the development of TMJ ankylosis is infectious inflammatory diseases of nearby organs. Bacteria enter the temporomandibular joint from other foci. Ankylosis can develop as a complication of the following diseases:
- otitis media;
- osteomyelitis of the lower jaw;
- periostitis;
- mastoiditis;
- arthritis;
- phlegmon in the jaw;
- neonatal sepsis;
- scarlet fever;
- diphtheria;
- gonorrhea.
Any purulent-inflammatory infections of the ENT organs and teeth can have such an unpleasant consequence as ankylosis.
The second cause of joint articular fusion is trauma to the jaw: fractures, dislocations and fissures. Such damage occurs when the chin bruises, for example, when falling from a height or with a direct impact. In infants, trauma to the lower jaw is possible during complex births if the obstetrician inaccurately placed forceps on the baby’s head. All these injuries are accompanied by hemarthrosis - bleeding into the intraarticular cavity. This can trigger ankylosis.
Pathology classification
There are several classifications of TMJ ankylosis.
By origin, this disease is divided into the following groups:
- congenital ankylosis;
- acquired ankylosis.
Congenital pathology is quite rare. Usually it is combined with other anomalies in the structure of the face. Most often, joint fusion is acquired in nature and occurs in the process of life.
It is customary to subdivide the disease also depending on its etiology:
- infectious ankylosis;
- traumatic ankylosis.
In the first case, pathology occurs as a complication of various purulent-inflammatory processes, and in the second, as a consequence of jaw injuries.
There is also a classification of TMJ ankylosis according to localization. The following types of joint damage are distinguished:
Most often, unilateral ankylosis is noted. Bilateral lesion is observed quite rarely, in only 7% of cases. Pathology occurs on the right or left side with the same frequency.
The disease is also classified depending on the type of pathological changes in the joints. In this regard, ankylosis of two types is distinguished:
What is the difference between these pathologies? In case of fibrous ankylosis of TMJ, the gap between the articular bones is filled with connective tissue. In this case, a person can make small movements with his jaw. They are usually accompanied by soreness. On the X-ray, you can notice a sharply narrowed gap between the articular bones. Such a pathology is usually observed in patients of mature age.
With bone ankylosis of TMJ, a person cannot make jaw movements. Pain syndrome is not observed. This form of the disease is accompanied by a complete fusion of bone surfaces. The gap between the joints is filled with bone tissue and is invisible in the x-ray. This type of pathology is characteristic of children and adolescents. It is important to remember that in an adult, a running fibrous form of ankylosis can go into bone. Over time, the connective tissue undergoes ossification.
Some doctors also identify partial and complete ankylosis of TMJ. In the first case, there are still remains of healthy cartilaginous tissue on the surface of the bones; in the second, the joint is completely fused.
Symptomatology
With ankylosis of TMJ, it becomes difficult for a person to make movements in the lower jaw. The patient has serious difficulty opening his mouth, chewing food, talking. At the beginning of the disease, it becomes difficult for the patient to perform only vertical movements with his jaw. As the disease progresses, difficulties arise with horizontal movements. When the disease passes from the fibrous form to the bone, a complete immobility of the jaw sets in.
At the fibrotic stage of a person, chronic pain in the jaw is disturbing. They arise not only when trying to move, but also at rest. The pain syndrome disappears as the ossification of the connective tissue. This indicates the progression of the disease. When a patient tries to open or close his mouth, clicks are heard.
The patient's face shape changes. With unilateral ankylosis, you can notice a shift in the middle facial line to the sick side. The patient develops a malocclusion: when the jaws are closed, the rows of teeth intersect.
In some cases, a noticeable weak development of the lower jaw. The chin looks beveled. Malocclusion is characteristic: the upper rows of teeth partially cover the lower. Such manifestations are noted in bilateral ankylosis of TMJ. Photos of external signs of pathology can be seen below.
Patients have respiratory distress. These manifestations are directly related to the immobility of the jaw. At night, there is a sudden cessation of breathing (apnea), snoring, often retreating of the root of the tongue.
In addition, impaired jaw movement negatively affects the condition of the gums and teeth. Patients often experience tooth decay, gingivitis and periodontal disease. This is due to the fact that because of the difficulty in opening the mouth, it is difficult for the patient to brush his teeth and undergo dental treatment.
Features of the disease in childhood
With ankylosis of TMJ in children, there is often a strong underdevelopment of the lower jaw. Such a defect is called a bird face, or microgenia. It is especially noticeable if you look at the baby in profile. Due to difficulty in chewing, the child cannot eat normally. This leads to slow weight gain and stunted growth.
In addition to facial deformation, children have abnormal tooth growth and malocclusion. A child can often suffer from gingivitis and stomatitis due to the inability to maintain oral hygiene. In young children, teeth erupt weakly.
A sick child has sleep disturbances due to breathing problems. Children wake up due to sudden asphyxiation. Often a child cannot sleep on his back, as his tongue and epiglottis sinks. In severe cases, babies can only sleep in a sitting position.
Damage to the temporomandibular joint affects the condition of the spine. There is a curvature of the cervical spine with muscle weakness. Chewing and facial muscles also lose their tone.
Ankylosis in a child progresses very quickly. This is due to active bone growth in childhood. Fibrous tissue in the joint space rapidly ossifies, and the disease goes into a more severe stage.
Complications
Without treatment, TMJ ankylosis can lead to serious complications. Respiratory disorders, which are often noted with this disease, are especially dangerous. They can be fatal. A falling tongue during sleep often causes vomiting. In this case, the contents of the stomach can enter the respiratory tract, which often causes asphyxiation.
For babies under the age of 1 year, attacks of night apnea are very dangerous. A small child is not always able to wake up with the occurrence of asphyxiation. This becomes one of the causes of SIDS (Sudden Infant Death Syndrome) when a baby dies in a dream from respiratory arrest.
With ankylosis of TMJ, a person loses the ability to eat normally. For this reason, the patient is rapidly losing weight. Weight loss can reach the stage of anorexia. Due to a lack of nutrition, the patient's general state of health worsens, weakness and a decrease in performance occur.
As already mentioned, in patients with ankylosis, teeth are often destroyed. Due to difficulties in opening their mouth, it is difficult for such patients to have a full dental treatment. In such cases, caries often leads to periostitis and phlegmon. In addition, bacteria from the oral cavity can spread through the bloodstream and cause inflammation in other organs.
Diagnostics
The treatment of this disease is performed by an orthopedic surgeon or surgeon. Examination of the patient begins with examination and palpation of the affected area. Facial asymmetry and malocclusion are detected. If the disease arose in early childhood, then there is a violation of the development and growth of teeth.
The patient is offered to open his mouth as much as possible. Moreover, in a patient with ankylosis, the distance between the upper and lower jaw is no more than 1 cm. Normally, a person can open his mouth at a distance equal to the width of three fingers.
On palpation, the doctor examines the mobility of the head of the joint. With ankylosis, lateral sliding movements are impossible.
The most reliable method for diagnosing ankylosis is an X-ray examination. With a fibrous form of pathology, a narrowed joint gap is visible in the picture. The edges of the bones in the joint can be thickened or have a normal shape. With full joint fusion, the head of the bone is destroyed, and the gap is not visible.
If necessary, additional studies are prescribed: cone beam computed tomography of the joint, electromyography and arthrography with contrast medium. It is important to separate ankylosis from tumors of the lower jaw.
Conservative treatment
Conservative therapy is indicated in the early stages of TMJ ankylosis. Treatment of the disease with medication and physiotherapy is effective in the fibrous form. The patient is prescribed injections of corticosteroid hormones into the joint cavity. Also used drugs that absorb the connective tissue:
- Lidazu
- Hyaluronidase
- "Potassium iodide";
- Hydrocortisone.
If adhesions in the joint are formed recently, then they resolve under the influence of such drugs.
At the same time, physiotherapeutic procedures are prescribed:
- ultrasound;
- phonophoresis.
However, such treatment only helps in the very early stages of "young" adhesions. In more advanced cases, they do redress. Under local anesthesia, the jaws are forced open. This procedure is carried out using special rotary expanders. After that, in most cases, a person is able to open his mouth at a distance of 3 cm.
After the redress, doctors recommend that you rest, take the prescribed antibiotics and analgesics. The rehabilitation period after such a procedure lasts about 3-5 days.
After the recovery period, mechanotherapy is indicated. Between the upper and lower jaw are placed special devices. They must be worn from 1 hour to several days. The course of therapy lasts about 3 weeks. Mechanotherapy in many cases helps to bring the opening of the mouth to a physiological norm of 4 cm.
Surgical intervention
With persistent fibrotic joint changes and in the bone form of pathology, surgical treatment of TMJ ankylosis is indicated. Carry out the following types of operations:
- Exarticulation. The head of the lower jaw is isolated, and then replaced with a graft.
- Osteotomy. Bone fusion is dissected and a new joint head is created. It is covered with a special cap.
- Dissection of scars. This operation is indicated for pathology of the fibrous type, not amenable to conservative therapy.
After surgical interventions, a splint or special devices are placed on the lower jaw . During the rehabilitation period, the patient needs therapeutic exercises for the masticatory muscles, dosed sessions of mechanotherapy, massage and physiotherapy.
Then the patient needs to correct the position of the teeth and the bite. To this end, orthodontic treatment is used. Braces, mouth guards and special devices for straightening the position of the jaws are placed on the jaw.
After surgery for ankylosis of the temporomandibular joint in some patients, the appearance normalizes and the asymmetry of the face disappears. But if the disease arose in childhood, then microgenia often persists after surgery. In this case, plastic is necessary for the lower part of the face.
Forecast
In the early stages, TMJ ankylosis lends itself well to conservative treatment. In more advanced cases, surgery will help correct the asymmetry of the face, restore normal breathing and speech.
However, there are severe forms of ankylosis that are difficult to respond even to surgical treatment. With them, the disease progresses even after the therapy. Therefore, treatment of TMJ ankylosis should be started as early as possible, at the first signs of joint mobility limitation.
Prevention
Prevention of ankylosis consists in the timely treatment of purulent-inflammatory diseases of the ENT organs and jaw injuries. Chin bruises and dislocations cannot be ignored. It is also necessary to monitor the condition of the teeth and, if necessary, carry out sanitation of the oral cavity.
If a child has facial asymmetry, poor teething and malocclusion, you should immediately contact a pediatric orthopedist. This may be a sign of congenital ankylosis. This condition requires immediate treatment, since in children the joint fusion very quickly passes into a severe bone form.