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Abnormal bony connections between the skull and the mandible
ABNORMAL
BONY CONNECTIONS BETWEEN THE SKULL AND THE MANDIBLE
T
Hli: mandible is normally connected to the skull hy means oI’: L1 ! mrtwlcs attached to both skull and mandible: (2) the c*ovtyring fasciae, skin, 01 mucous membrane; (3) certain ligaments; and (1) the capsule of the t emporomandibular joint. TJpscts or abnormalities in any of these structures t~a,v cause clit%ic\~lty in OP such upsets. opening the mouth. The following arc some csa~nples 1. Muscles.-Muscles may contr;tc+ reflexly in response to some irritation of t,he nerve ends in t.hcs mouth or ihe throat wgion. Thv wndition is known as trismus, and is seen frequent]\- as iln acconll,anirnerlt to pericoronitis around an erupting lower third molars. The muscles may be unahlt~ to wlax because ot’ the infiltrat.ion of inflam matory exudate among their fibers. This c~ondition is encounterctl in cascxs 0I rrllulitis spreading to the int rrcrllular musrular tisslkt>--from a caw of paret itis, -for example. The muscles may be unable to relax l~causc ot’ the (donversion of some of their fibers into bone. This condit,ion is known as nlyositis ossii’ic+ans ;jn(l usually affects more than one muscle in t h(l body. 2. The Covering Skin or Mucous Membrane.-Sometimes some of the skill or the mucous membrane is lost hecausc of trauma, infection, 01’ ir1xctiation. The healing process may result in scar forluation which: b\, contraction. hinders t hc normal movements of the mandibl(i.
3. The Ligaments.-Ossitic.Htioll lay, or pterygomandibular tion.
ligament
itr tht? sl)hcnoln;~~ltlih~~lar, stylortl;rllclil)llwill n;tt,urally fis the mandible in one posi-
4. The Capsule of the Temporomandibular
Joint.--Extrx-at.tic!nlar
atlky-
losis. Fibrosis in t,he capsule, subsequent to any affection, causths difficult!: in opening the mouth. Bony union between the mandibular condyle and the glenoid fossa of the temporal bone leads to unilateral or double ankylosis, according to whether one or both joints are affected. From the preceding, it may be deduced that abnormal bony union between the skull and the mandible may be classified under three categories : (1) myositis ossificans in muscles of mastication; (2) ossification in the ligaments conFrom
the Dental
Section,
University
of Alexandria. 954
ABNORMAL
BONY
COSNECTIONS
BETWEEN
netting the mandible to the skull; and mandibular joint, whether unilateral or may be mentionccl : bony union between ilntl the nmsilla. The cases to be presented sewc to bony cxonnections.
SKULL
AND MANDIBLE
9%
(3) bony ankylosis in the temporobilatwal. Jloreover, a fourth group process 01: the mandible the cwtwwitl dcmonstraie
some of’ thrsc abnormal
Myositis Ossificans Myositis, in general, is either acute or chronic. Acute myositis is subdivided, according to cause, into the traumatic a.nd the infective types. Chronic myositis may be either specific (tubcrculosis~ syphilis, or actinomycosis) or simple, which is (lither fibrous or osseous. The osseous type, ‘ ’ myositis ossificans, ” may be partial and circumscribed (osteoma ), the cause being a single or repeat,ed trauma, or progressive and generalized, when it dcvcloys by three steps of infiltration into the connect~ive system of ihc muscle, namely by embryonic infiltration of connective tissue, fibrous induration. and ossification. The cause of mgositis ossificans is unknown. It is thought to be of infective origin. It is a rare condition and has a predilection to affect males. The first muscles to be affected are those of the neck, back, and thorax, and, later on, those of the limbs. The disease advances b,v exacerbations until all the muscles of t,hc body, including those of the jaws, become affected. Case Reports Case I.--The case presented here is that of a Negro boy (M. Ii.), came to the hospital on May 13, 1951, complaining of complete inability
aged 18 years. He to open his mouth.
He stated that the condition had started gradually about one yrar beforc. It was observed The trunk was twixtcad to the left side, while the that the gait of the patient was strange. The patient did not complain of pain anywhere in the neck was bent to the right side. Apart from his inability to open his mouth and the abnormal gait, the boy was all body. The condition was suspected to be ossifying spond$it,is (Marie-Striimpbell !s disease), right.
956
M. S. GRIDLY
Case 2.-The patient, A. I., was a married woman, 23 years of age. She came to thr hospit,al on Nov. 8, 1951> complaining of a progressive inability to open the mouth. She stated that when she was 4 years old she fell on the stairs, and there was bleeding from her left ear and from her mouth. Her chin was wounded at the time, and the scar was still present. The patient had complained since of partial inability t,o open her mouth. On examination, only one finger tip could be passed between the front teeth. Normal movement
ABNORMAL
BONY
CONNECTIONS
BETWEEN
SKUIJ,
ASD
MASDIBIX
xi7
could be felt in the right joint on opening the mouth, while the movement of the left joint The mandiblr was noted to deviate to the left side. There WRA was very much restricted. Two months prwionsly, liain arts felt nt tlw some ffattening of the right side of the faw. region of the left joint. On palpation, a notch was felt in front of the angle of the nlandible. On clenching the teeth, the left temporal muscle was felt to be weaker than the right one, \vhilc thr The patient was admitted to the, masseters of both sides seemed to be of the same strength. hospital, the case being diagnosed by s-ray and clinical examination as left tcmporomantlib~~l:~~ ankylosis. She was given penicillin and, on Nov. 26, 1951, she was taken to the operating tlrcatez where an attempt was made to perform an operation under lorxl anesthesia,. This tlicl not prove successful, so intrawnous Pentothal sodium, followed by c+hcr, was used. A vertical incision was madc in front of the lt,ft tragus, tissues were rrflectcsd, and thcb bone in the conclylar region was chisclrd off until the mouth caould be opened. Three days later the patient complained of continuous dizziness, headache, and inabilit,y to walk. This \V:LS due to xeaknrss of the extensor muscles of thr: feet. Tonics, calcium, and vitamins were given ant1 the pati,,l,t walked rmaitlcd in one week ‘S time. On rkc. 15, 19.51, thca patient was all right, conltl open her month fully, and was tlulp diwhargcd.
A.
Fix.
::.-(Yasc
:1. Double
6.
ankylosis. -4, Amount of opening achieved called “bird’s Paw” in profile.
after
operation
: Ii. so-
Double Ankylosis Case 3.-The patient, A. X., was a li-year-olcl Kv::lo /JO)-, srut 10 me for allvicts ;Il)out 11~ stated t.hat eight ~vxrs l~reviously lie fdl from :L swontlhis pwmanently closed mouth. floor window to the street. fracturing a lrg and aquiriug an inviae(l wound in tlw chin. IIr: was taken to the loral hospital, whwe the- 1t.g fracture was :lt twnl4 to and the (.lrin ~w~un~l Although 11e had some blf,edin g from thy mouth, the condition of thib ,j;~ws was stitched.
958
b‘ig.
RI. S. GRIDT,Y
4:-Case
4.
Bony
union
between coronoid temporomandibular
process and mandible ankylosis.
in addition
to I~,ft
ABNORMAI,
BOSY
COSSECTIONS
BETWEEN
SKIJLL
AND
MANDIBLE
959
was not investigated, and no x-ray films of the skull were made. When t,he condition of his Since his fall, the patient leg was satisfactory he was discharged from the local hospital. The difficulty increased as time went by. experienced difficulty when eating. On examination, t.hc patient was observed to ha\ e an old soar in the chin. The chin was receding bclcxuse of the undcrclevclopn~unt of the maudible subxrqucant to the injury which resulted in inflicted upou the growth centers in the> coudyles at the time oE the accident, He could separate the frout, teeth. with difficulty, to a space of a so-cslled ‘(bird’s face.” only 1 or 2 mm. The scar in the chin suggested that at the time of the accident, the patient fell on his chin and probably fractured the necks of both mandibular condylrs. The palpating fingers felt litth~, if any, movement in the tcmporomandibular joints while the patient was Apart from the symmetrical facial crippling, the general trying hard to open his mouth. condition of the patient was satisfactory, considering that ha had subsisted solely on fluids since his accident. Both temporomandibular joints were x-rayed and a diagnosis of doublr~ ankylosis was made. on both On Aug. 28, 1952, tile patient was put uuder ondotrachcal cbther. 1 oprratrd sidrs a.t the same swsion. At first a condylectomy was contemplated but, when the area was revealed, so much scar bouc3 was found that it was thought better to carcatc a new joint at the subcondylar rc,gion (a sort of “high Esmarch” operation). The mouth could be opened su&iently after the double operation. Exercises were advised and the patient, was glad to pursue them mt,husiastically. Healing was rapid and uneventful. dt the present stage (.TnncJ, 1953) the patient is getting along nicely.
Union Between Coronoid Process and Maxilla on April 2, 1951, Case 4.---The patient, M. O., aged 23 years, came to the hospital complaining of inability to open his mouth. Ile stated that iu 1936, when he was 8 years old, he had some affection in his left maxilla, for which an operation was performed. He could not tell what that affection was, but it was vaguely gathered that the affection might have Afterward, the patient experienced progressive been osteomyeIitis with bone necrosis. One year later (1939), the inability to open was almost difficulty in opening his mouth. mouth had complete and had remained so ever since. For the last twelve years, the patient’s been practically completely closed. On examination, he was obserrrd to have a depressed left cheek. No movement could be detected in the condylar region on the left, no matter how hard the patient tried to force the X-ray jaws open. A very slight movement could be detected in the right condylar region. films showed ankylosis of the left condyle, which was attached to the base of the skull. On May 2, 1951, a left condylectomy was pcxrformed. Still the mouth could not be opened, so the field of operation was widened and it was then evident that there was bony union between the coronoid process and the back of the maxilla. TVhcan this connection was severed, the mouth could be opened to a reasonable laxtent.
References ed. 3, Pl~iladclpl~ia and London, 1949, \I’. of Surgery, 1. Christopher, F. : Textbook Saunders Company, p. 112. Oral Pathology, ed. 3, St. Louis, 1951, The C. V. Afosby Company. 2. Thoma, K. H.:
1%.
BONY CONNECTIONS BETWEEN THE SKULL AND THE MANDIBLE
T
Hli: mandible is normally connected to the skull hy means oI’: L1 ! mrtwlcs attached to both skull and mandible: (2) the c*ovtyring fasciae, skin, 01 mucous membrane; (3) certain ligaments; and (1) the capsule of the t emporomandibular joint. TJpscts or abnormalities in any of these structures t~a,v cause clit%ic\~lty in OP such upsets. opening the mouth. The following arc some csa~nples 1. Muscles.-Muscles may contr;tc+ reflexly in response to some irritation of t,he nerve ends in t.hcs mouth or ihe throat wgion. Thv wndition is known as trismus, and is seen frequent]\- as iln acconll,anirnerlt to pericoronitis around an erupting lower third molars. The muscles may be unahlt~ to wlax because ot’ the infiltrat.ion of inflam matory exudate among their fibers. This c~ondition is encounterctl in cascxs 0I rrllulitis spreading to the int rrcrllular musrular tisslkt>--from a caw of paret itis, -for example. The muscles may be unable to relax l~causc ot’ the (donversion of some of their fibers into bone. This condit,ion is known as nlyositis ossii’ic+ans ;jn(l usually affects more than one muscle in t h(l body. 2. The Covering Skin or Mucous Membrane.-Sometimes some of the skill or the mucous membrane is lost hecausc of trauma, infection, 01’ ir1xctiation. The healing process may result in scar forluation which: b\, contraction. hinders t hc normal movements of the mandibl(i.
3. The Ligaments.-Ossitic.Htioll lay, or pterygomandibular tion.
ligament
itr tht? sl)hcnoln;~~ltlih~~lar, stylortl;rllclil)llwill n;tt,urally fis the mandible in one posi-
4. The Capsule of the Temporomandibular
Joint.--Extrx-at.tic!nlar
atlky-
losis. Fibrosis in t,he capsule, subsequent to any affection, causths difficult!: in opening the mouth. Bony union between the mandibular condyle and the glenoid fossa of the temporal bone leads to unilateral or double ankylosis, according to whether one or both joints are affected. From the preceding, it may be deduced that abnormal bony union between the skull and the mandible may be classified under three categories : (1) myositis ossificans in muscles of mastication; (2) ossification in the ligaments conFrom
the Dental
Section,
University
of Alexandria. 954
ABNORMAL
BONY
COSNECTIONS
BETWEEN
netting the mandible to the skull; and mandibular joint, whether unilateral or may be mentionccl : bony union between ilntl the nmsilla. The cases to be presented sewc to bony cxonnections.
SKULL
AND MANDIBLE
9%
(3) bony ankylosis in the temporobilatwal. Jloreover, a fourth group process 01: the mandible the cwtwwitl dcmonstraie
some of’ thrsc abnormal
Myositis Ossificans Myositis, in general, is either acute or chronic. Acute myositis is subdivided, according to cause, into the traumatic a.nd the infective types. Chronic myositis may be either specific (tubcrculosis~ syphilis, or actinomycosis) or simple, which is (lither fibrous or osseous. The osseous type, ‘ ’ myositis ossificans, ” may be partial and circumscribed (osteoma ), the cause being a single or repeat,ed trauma, or progressive and generalized, when it dcvcloys by three steps of infiltration into the connect~ive system of ihc muscle, namely by embryonic infiltration of connective tissue, fibrous induration. and ossification. The cause of mgositis ossificans is unknown. It is thought to be of infective origin. It is a rare condition and has a predilection to affect males. The first muscles to be affected are those of the neck, back, and thorax, and, later on, those of the limbs. The disease advances b,v exacerbations until all the muscles of t,hc body, including those of the jaws, become affected. Case Reports Case I.--The case presented here is that of a Negro boy (M. Ii.), came to the hospital on May 13, 1951, complaining of complete inability
aged 18 years. He to open his mouth.
He stated that the condition had started gradually about one yrar beforc. It was observed The trunk was twixtcad to the left side, while the that the gait of the patient was strange. The patient did not complain of pain anywhere in the neck was bent to the right side. Apart from his inability to open his mouth and the abnormal gait, the boy was all body. The condition was suspected to be ossifying spond$it,is (Marie-Striimpbell !s disease), right.
956
M. S. GRIDLY
Case 2.-The patient, A. I., was a married woman, 23 years of age. She came to thr hospit,al on Nov. 8, 1951> complaining of a progressive inability to open the mouth. She stated that when she was 4 years old she fell on the stairs, and there was bleeding from her left ear and from her mouth. Her chin was wounded at the time, and the scar was still present. The patient had complained since of partial inability t,o open her mouth. On examination, only one finger tip could be passed between the front teeth. Normal movement
ABNORMAL
BONY
CONNECTIONS
BETWEEN
SKUIJ,
ASD
MASDIBIX
xi7
could be felt in the right joint on opening the mouth, while the movement of the left joint The mandiblr was noted to deviate to the left side. There WRA was very much restricted. Two months prwionsly, liain arts felt nt tlw some ffattening of the right side of the faw. region of the left joint. On palpation, a notch was felt in front of the angle of the nlandible. On clenching the teeth, the left temporal muscle was felt to be weaker than the right one, \vhilc thr The patient was admitted to the, masseters of both sides seemed to be of the same strength. hospital, the case being diagnosed by s-ray and clinical examination as left tcmporomantlib~~l:~~ ankylosis. She was given penicillin and, on Nov. 26, 1951, she was taken to the operating tlrcatez where an attempt was made to perform an operation under lorxl anesthesia,. This tlicl not prove successful, so intrawnous Pentothal sodium, followed by c+hcr, was used. A vertical incision was madc in front of the lt,ft tragus, tissues were rrflectcsd, and thcb bone in the conclylar region was chisclrd off until the mouth caould be opened. Three days later the patient complained of continuous dizziness, headache, and inabilit,y to walk. This \V:LS due to xeaknrss of the extensor muscles of thr: feet. Tonics, calcium, and vitamins were given ant1 the pati,,l,t walked rmaitlcd in one week ‘S time. On rkc. 15, 19.51, thca patient was all right, conltl open her month fully, and was tlulp diwhargcd.
A.
Fix.
::.-(Yasc
:1. Double
6.
ankylosis. -4, Amount of opening achieved called “bird’s Paw” in profile.
after
operation
: Ii. so-
Double Ankylosis Case 3.-The patient, A. X., was a li-year-olcl Kv::lo /JO)-, srut 10 me for allvicts ;Il)out 11~ stated t.hat eight ~vxrs l~reviously lie fdl from :L swontlhis pwmanently closed mouth. floor window to the street. fracturing a lrg and aquiriug an inviae(l wound in tlw chin. IIr: was taken to the loral hospital, whwe the- 1t.g fracture was :lt twnl4 to and the (.lrin ~w~un~l Although 11e had some blf,edin g from thy mouth, the condition of thib ,j;~ws was stitched.
958
b‘ig.
RI. S. GRIDT,Y
4:-Case
4.
Bony
union
between coronoid temporomandibular
process and mandible ankylosis.
in addition
to I~,ft
ABNORMAI,
BOSY
COSSECTIONS
BETWEEN
SKIJLL
AND
MANDIBLE
959
was not investigated, and no x-ray films of the skull were made. When t,he condition of his Since his fall, the patient leg was satisfactory he was discharged from the local hospital. The difficulty increased as time went by. experienced difficulty when eating. On examination, t.hc patient was observed to ha\ e an old soar in the chin. The chin was receding bclcxuse of the undcrclevclopn~unt of the maudible subxrqucant to the injury which resulted in inflicted upou the growth centers in the> coudyles at the time oE the accident, He could separate the frout, teeth. with difficulty, to a space of a so-cslled ‘(bird’s face.” only 1 or 2 mm. The scar in the chin suggested that at the time of the accident, the patient fell on his chin and probably fractured the necks of both mandibular condylrs. The palpating fingers felt litth~, if any, movement in the tcmporomandibular joints while the patient was Apart from the symmetrical facial crippling, the general trying hard to open his mouth. condition of the patient was satisfactory, considering that ha had subsisted solely on fluids since his accident. Both temporomandibular joints were x-rayed and a diagnosis of doublr~ ankylosis was made. on both On Aug. 28, 1952, tile patient was put uuder ondotrachcal cbther. 1 oprratrd sidrs a.t the same swsion. At first a condylectomy was contemplated but, when the area was revealed, so much scar bouc3 was found that it was thought better to carcatc a new joint at the subcondylar rc,gion (a sort of “high Esmarch” operation). The mouth could be opened su&iently after the double operation. Exercises were advised and the patient, was glad to pursue them mt,husiastically. Healing was rapid and uneventful. dt the present stage (.TnncJ, 1953) the patient is getting along nicely.
Union Between Coronoid Process and Maxilla on April 2, 1951, Case 4.---The patient, M. O., aged 23 years, came to the hospital complaining of inability to open his mouth. Ile stated that iu 1936, when he was 8 years old, he had some affection in his left maxilla, for which an operation was performed. He could not tell what that affection was, but it was vaguely gathered that the affection might have Afterward, the patient experienced progressive been osteomyeIitis with bone necrosis. One year later (1939), the inability to open was almost difficulty in opening his mouth. mouth had complete and had remained so ever since. For the last twelve years, the patient’s been practically completely closed. On examination, he was obserrrd to have a depressed left cheek. No movement could be detected in the condylar region on the left, no matter how hard the patient tried to force the X-ray jaws open. A very slight movement could be detected in the right condylar region. films showed ankylosis of the left condyle, which was attached to the base of the skull. On May 2, 1951, a left condylectomy was pcxrformed. Still the mouth could not be opened, so the field of operation was widened and it was then evident that there was bony union between the coronoid process and the back of the maxilla. TVhcan this connection was severed, the mouth could be opened to a reasonable laxtent.
References ed. 3, Pl~iladclpl~ia and London, 1949, \I’. of Surgery, 1. Christopher, F. : Textbook Saunders Company, p. 112. Oral Pathology, ed. 3, St. Louis, 1951, The C. V. Afosby Company. 2. Thoma, K. H.:
1%.