arthrocentesis and arthroscopy · patients diagnosed with tmj disease: when is surgery indicated ?...

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Current State of Surgical and Non Surgical Treatment Options for

Patients Diagnosed with TMJ Disease: When is Surgery Indicated ?

PRINCIPLES AND PRACTICE OF TMJ PROCEDURES:

ARTHROCENTESIS AND ARTHROSCOPY

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Goals and Objectives

1) To understand the principles of,

diagnosis of, and techniques of

TMJ treatment: specifically

Arthrocentesis and Arthroscopy,

Arthroplasty and Total Joint Replacment

2) To perform the various TMJ

procedures covered in this course

Diagnosis of TMJ Dysfunction

1. History – Chief Complaint

– HPI

• Onset

• Precipitating cause

• Signs and Symptoms

Diagnosis of TMJ Dysfunction

• Past Medical History – General Medical Problems – General Psycho/Social Problems • Personal/Familial/Professional

– Habits – Past Trauma – Past Surgeries – Medications

• Review of Systems

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Physical Exam

1. Head and Neck

– Pathology

• Intra-oral

• Extra-oral

– Muscular Exam

• Intra-oral

• Extra-oral

Physical Exam

1. Dental Exam – Clinical

– Radiographic/Imaging – Panorex

– Tomogram

– Arthrogram

– MRI

– Conventional CT

– CBCT

TOMOGRAM ARTHROGRAM CBCT

CBCT REFORMATED

MRI CLOSED

MRI OPEN

3D RECONSTRUCTION

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Anatomy of TMJ

• Hard Tissues – Condyle

• Medial/Lateral/Anterior/Posterior Poles

– Glenoid Fossa • Shallow/Deep/Flat/Concave

– Articular Eminence • Steep/Flat/Wide/Narrow

– EAM • Thin/Thick

Anatomy of the Temporomandibular Joint

Anatomy of TMJ • Soft Tissue

– Capsule • Dense fibrous membrane encompassing TMJ and

articular eminence

– Meniscus (Fibro-cartilage disc similar to ear cartilage dividing the joint space into upper/lower synovial cavities)/ Articular-cartilage (Hyaline) • Biconcave (post/4mm, mid/2mm, ant/3mm)

• Avascular/Aneural

– Ligaments/(Tendons/Muscles) • Post/Med/Lat Ligaments

• Lateral Pterygoid (superior belly)/Condylar Head and Disc

• Lateral Pterygoid (inferior belly)/Condylar Neck

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Anatomy of TheTemporomandiblar Joint

TMJ/Knee (Synovial) Joint

TMJ/Knee (Synovial) Joint

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Anatomy of TMJ

Blood Supply

a) External

Carotid Artery

b) Internal

Maxillary

Artery

c) Transverse

Facial Artery

d) Middle

Meningeal

Artery

g) Anterior

Tympanic

Artery

Anatomy of TMJ

Blood Supply

a) External

Carotid Artery

b) Internal

Maxillary Artery

f) Inferior

Dental Artery

g) Middle

Meningeal

Artery

Other blood supply not

visualized:

Deep auricular artery

Anterior Tympanic artery

Ascending pharyngeal artery

Blood and Nerve Supply

Senerory Innervation (V3)

1) Auriculotemporal

2) Masseteric

Proprioceptive receptors

1)Ruffini endings:

Static mechanoreceptors

2)Pacinian corpscles: dynamic

mechanoreceptors

3)Golgi tendon organs:

protect ligaments

4)Free nerve endings: pain

receptors to protect TMJ

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Anatomy of The Tempormandibular Joint

Controlling Pathology

–Needing to control the cause of the pathology is still the primary concern

– Inflammatory changes within the synovial fluid secondary to trauma infection or disease creates cartilage and bony breakdown

• Controlling inflammatory responses is key

Controlling Pathology

» Acute inflammation is characterized as lasting minutes, hours, up to a few days

» Chronic inflammation is characterized as lasting longer and non remitting for the period of time concerned

» Inflammation consists of 2 main components • Vascular changes… increased blood flow to area • Increased vascular permeability… to cellular

components

• Leukocyte or Neutrophil increase as first responders

• Proteins leak out of vessels (Exudate) to produce swelling

• Chemical mediators of pain released from cellular response to produce pain

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Pathogenesis of Pain and Inflammatory Responses

• Knowledge about the pathogenesis on a molecular level of disorders of the TMJ has been improved in recent years giving a possibility to use these data for the evidence based treatment. Inflammation mainly affects the posterior disc attachement (Holmlund & Axelsson, 1996; Leibur et al., 2010). Several inflammatory mediators play an important role in the pathogenesis of TMJ diseases as tumor necrosis factor ┙ (TNF┙), interleukin-1┚ (IL-1┚), prostaglandin E2 (PGE2), leukotrien B4 (LkB4 ), matrix metalloproteinases (MMPs), serotonin- 5- hydroxytryptamine (5-HT), (Alstergren et al., 1999; Voog et al., 2003b). MMPs are responsible for the metabolism of extracellular matrix, being an early marker to determine TMJ arthritis. High level of MMP-3 has been determined in the synovial fluid in TMJ osteoarthritis patients (Kamada et al., 2000). Serotonin, mediator of pain and inflammation, is produced in the enterocromaffin cells of the gastrointestinal mucosa and absorbed by platelets. It is produced also in the synovial membrane and is present in the synovial fluid and in blood in case of rheumatoid arthritis and is involved in the mediation of TMJ pain in systemic inflammatory joint diseases (Alstergren & Kopp, 1997; Voog et al., 2000).

Pathogenesis of Degenerative TMJ

• “Based on recent findings, models of degenerative TMJ disease predict that mechanical loads trigger a cascade of molecular events leading to disease in susceptible individuals. These events involve the production or release of free radicals, cytokines, fatty acid catabolites, neuropeptides, and matrix-degrading enzymes.”

Stephen B. Milam Odontology(2005) 93:7-15

Pathophysiology of TMJ Dysfunction

»Creates inflammatory response and release of chemical mediators of pain

• Generation of highly reactive molecules (free radicals) in response to mechanical stimulation, ultimately creating adhesions through oxidation-reduction reactions (Milam 2005 Odontology)

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1. Intracapsular dysfunction

– Macrotrauma/Microtrauma

• Mechanical dysfunction of the disc

– Creates inflammatory response and release of chemical mediators of pain

» Bradykinin, leukotriene B4, prostaglandin E2, and substance P levels influence success rates in arthrocentesis procedures OMFS 2007 Feb;65(2):242-7 Kaneyama K, Segami N, Sato J, Fujimura K, Nagao T, Yoshimura H.

Arthridities

• Osteoarthritis – Chronic disease process in which degeneration and

loss of articular cartilage occur together with new bone formation at the joint surfaces and margins, leading to pain and deformity

– Results in reduction of proteoglycan content in cartilage, leading to reduced resiliency and deterioration

– The body is unable to repair articular cartilage, so the underlying bone response by remodeling and forming bone spurs (osteophytes)

Arthridities

– Rheumatoid Arthritis

• Autoimmune disease which attacks the joints via the synovial linings of the joints creating inflammatory reactions and release of degradative enzymes ultimately breaking down articular cartilage causing bony deformation

– Psoriatic Arthritis

• Autoimmune disease

– Gouty Arthritis

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TMJ Degenerative Processes


• Once the source of the pathology is determined what is done to treat it – Start off conservatively

• Must control the cause of the pathology – Reduce trauma/inflammation

– Non surgical management • Splint therapy

• Medicinal therapy

• Control parafunctional habits

• Control psychological/social influences


• What to do if conservative treatment is unsuccessful

• Categorize internal joint disc pathology

– Wilkes Classification

• Wilkes Class I-V

• Most research is or should be done with this classification to standardize research results

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Wilkes Classification of Internal Joint Derangements

• Class I: Painless clicking. No restricted motion. Slight forward displacement of disk.

• Class II: Occasional painful clicking, intermittent locking, headaches. Slight forward displacement of disk, beginning deformity, and slight thickening of posterior edge.


• Class III: Frequent pain, joint tenderness, headaches, locking, restricted motion, and painful chewing. Anterior disk displacement with significant deformity/prolapse of disk. Class IV: Chronic pain, headaches, and restricted motion. Increase in severity from III with early to moderate degenerative changes, flattening of eminence, deformed condylar head, sclerosis.


• Class V: Variable pain, joint crepitus, and painful function. Disk perforation, filling defects, gross anatomic deformity of disk and hard tissues with degenerative arthritic changes.

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Disc Dispacement

• Dr. Joe Van Sickels published a paper in the 80’s regarding disc position and it’s importance in outcomes – Study included 100 patients

– Pre op imaging disclosed ADD without reduction– closed locks Wilkes Class III

– Arthrotomy procedure performed with distal wedge and sutured disc back into position

– After 6 months re imaging revealed 60% of discs were again ADD without reduction yet they still had increase MIO and decreased pain compared to pre-op

Anterior Disc Displacement

TMJ Treatment Algorithm

Conservative treatment

Arthrocentesis Arthroscopy

Open Joint

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Arthrocentesis

• Purpose number one

– By overfilling superior joint space allows for separation of the suction cup effect and will separate some less fibrous adhesion

Arthrocentesis

• Purpose number two

– Irrigate the superior joint space and flush out all synovial fluid contents which contain chemical mediators of pain, allowing the body to replenish with new synovial fluid void of these substances

Arthrocentesis/Arthroscopic Technique

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Holmlund-Hellsing Line

• A line is drawn from the lateral canthus to the most posterior and central point on the tragus

The posterior point of entry is located along the canthotragal line 10 mm from

the middle of the tragus and 2 mm below the canthotragal line. This is the approximate area of maximum concavity of the glenoid fossa

(Point A)

Holmlund-Hellsing Line

• The anterior point of entry is placed 10 mm further along the canthotragal line and 10 mm below it (Point B)

• Always remember the distance from skin to the center of the joint space is about 25 mm

Arthrocentesis/Arthroscopic Techniques

• Arthrocentesis is actually the beginning steps of Arthroscopic Surgery

• Multiple techniques (S. Tozoglu et al. 2010 British Journal OMS) – Arthrocentesis

• Single needle (Guarda-Nardini)(Rahal)

• Double needle…. Both posterior to eminence (Alkan)

• Double needle…. One needle posterior, one needle anterior (Nitzen et al.)

• All techniques utilize 2-300cc

of fluid (usually LR)

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Arthrocentesis/Arthroscopic Techniques

• Arthroscopic Technique – Multiple approaches depending on which part of the

joint you are interested in looking at • Superior posterolateral (3) • Superior anterolateral (1) • Endaural (2) “A review of techniques of lysis and lavage of the TMJ” (S. Tozoglu et al. 2010 Bristish Journal of OMS)

Techniques of Arthroscopic Surgery

• Most common is the superior postero-lateral approach providing visualization of the majority of the superior joint space

• The superior antero-lateral approach allows for visualization of the antero-superior joint compartment

• The Endaural approach is for visualization of the posterior superior joint space and medial and lateral paradiscal troughs

Traditional Arthroscopy in the OR

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Measure interincisal opening distance under general anesthesia

Otoscopic examination of tympanic membrane preoperatively

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Draw landmarks

Feel the “step off”

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DISTEND SUPERIOR JOINT SPACE

FEEL “BOUNCE BACK”

SHARP TROCAR/CANNULA TO LATERAL LIP OF TEMPORAL BONE, FEEL STEP OFF

HIGH FINGER STOP

18/20 GAUGE NEEDLE OUTFLOW

DIAGNOSTIC ARTHROSCOPY

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OPERATIVE ARTHROSCOPY REQUIRES ANTERIOR PORTAL

SHARP TROCAR AND CANNULA

ANTERIOR PORTAL

25 mm ANTERIORLY

10 mm INFERIORLY

OPERATIVE ARTHROSCOPY REQUIRES TRIANGULATION

WORKING CANNULA WITHIN THE VISUAL FIELD OF THE ARTHROSCOPE

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OPERATIVE ARTHROSCOPY

REQUIRES TRIANGULATION


Triangulation

OPERATIVE ARTHROSCOPY REQUIRES TRIANGULATION


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LYSIS OF ADHESIONS

BIOPSY PATHOLOGIC TISSUE WITH ALLIGATOR FORCEPS

Cartilaginous Breakdown in the Knee

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MOTORIZED SHAVING WITH MINI-SHAVER & FULL RADIUS 2 mm BLADE

DIRECT STEROID INJECTION INTO INFLAMED SYNOVIAL TISSUE

IRRIGATE SUPERIOR JOINT SPACE AT END OF PROCEDURE

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New Options: In Office Arthroscopy

Advantages • Reduced costs • Control of scheduling & costs • Insurance issues often greatly reduced • Simple operative arthroscopy

– Lysis & lavage – Direct subsynovial steroid injections – Indirect discal mobilization – Advanced techniques possible

Auriculotemporal Nerve Block

Auriculotemporal nerve

Complications

• Arthrocentesis – Facial paralysis – typically frontal branch of CN VII

– Lingual Parasthesia

– Otic injury

– Articular cartilage damage

– Pre auricular hematoma/extravasation

– Intracranial perforation

– Infection

(S. Tozoglu et al. / British Journal of OMS 2010)

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Otic Injury

Complications

• Arthroscopic Surgery .1%-10.3% – Facial paralysis – typically frontal branch of CN VII – Lingual Parasthesia – Otic injury (blood on, or perf of TM, Vertigo, Lac) – Articular cartilage damage – Pre auricular hematoma/extravasation – Intracranial perforation – Infection – Broken instrumentation – Death (S. Tozoglu et al. / British Journal of OMS 2010)

Case Series - Outcomes of TMJ Arthroscopy

• Sanders, Buoncristiani. J Craniomand Dis 1:202, 1987

• Moses, Poker. J Oral Maxillofac Surg 47:790, 1989

• Indresano. J Oral Maxillofac Surg 47:439, 1989

• Israel, Roser. J Oral Maxillofac Surg 47:570, 1989

• Montgomery, et al. J Oral Maxillofac Surg 47:1263, 1989

• McCain, Sanders, Koslin, et al. J Oral Maxillofac Surg 50:926, 1992

• Hoffman, Cubillos. J Craniomand Pract 12(1):11, 1994

• Murakami, et al. Oral Surg Oral Med Oral Pathol 80:253, 1995

• Murakami, et al. J Oral Maxillofac Surg 54:285, 1996

• Fridrich, Wise, Zeitler. J Oral Maxillofac Surg 54:816, 1996

• Chossegros, et al. Br J Oral Maxillofac Surg 34:504, 1996

• Dimitroulis. J Oral Maxillofac Surg 60:519, 2002

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Disc Repositioning and Arthroplsaty

• TMJ dysfunction is a common condition an estimated 12-87% of the American population has reported at least one sign of TMJ Dysfunction.

• Anterior +/- medial displacement of the articular disc is the most common condition causing joint dysfunction.

• Gale A, Gross EN.J Am Dent Assoc 1983:107: 835-842

• Flynn B, Brown DT, Lapp TH. Oral Surg Oral Med Oral Pathol 1990: 70 372-380

• Disc displacement can result in

• Decreased Joint Space • Clicking/Popping/Crepitation • Arthritis • Condylar resorption • Jaw deformities • Malocclusion • Compression of the bi-laminar tissue

Wilkes CH. NW Dent 1978: 57: 287-290

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• Chronic disc displacement can lead to • Deformation of the disc • Loss of flexibility • Loss of vascularization of the disc • Breakdown of the fibrocartilagenous covering of

the condyle • Perforation of the disc

Wilkes CH. NW Dent 1978: 57: 287-290

– All changes of chronic disc displacement are manifested clinically as progressively worsening jaw function and pain

• Annandale first described surgical repositioning of the TMJ disc in 1887.

• It was not until 1978 when Wilkes used arthrography that disc repositioning became an accepted surgical technique.

• Annandale T. Lancet 1887: 1: 411-412 • Wilkes CH. Minn Med 1978: 61: 645

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• Disc displacement is often accompanied by a loss of structural integrity of the posterior band, medial and lateral ligaments

• Traditional repositioning techniques involve plication of these inflamed and degenerated ligaments

• Mercuri LG. J Oral and Maxillofac Surg 1989 47:153-154 • Mercuri: Surgical Management of TMJ Pathology, 9th international Conference in Oral Surgery. May 1986

• Traditional disc plication is described as reduction of the lateral pole of the condyle to create a bleeding surface.

• The condyle is inferior distracted and the disc released from the medial ligament and posterior band to allow the disc to fall in an anterior superior position.

Weinberg S, Cousens G. Meniscondylar plication: Surgical repositioning of the TMJ meniscus. Oral Surg, Oral Med, Oral pathol 1987;63 393-402

• The lateral border of the disk was secured to the lateral aspect of the capsule to reinforce the posterior lateral repositioning of the disc.

• The disc was sutured with Prolene/Nylon 3-0 through the intermediate zone and posterior band and attached to the condyle.

Weinberg S, Cousens G. Meniscondylar plication: Surgical repositioning of the TMJ meniscus. Oral Surg, Oral Med, Oral pathol 1987;63 393-402

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• To overcome plication of inflamed ligaments in 1997 Wolford et al developed a surgical bone anchor (Mitek Anchor) for stabilizing the TMJ articular disc.

• Mitek anchors originally were developed for orthopedic surgery in 1991.

• Woldford LM. Oral Surg Oral Med Oral Pathol 1997: 83: 143-149 • Obrist J. Unfallchirugie 1991: 17: 208-213

• The Mitek mini anchor is cylindrical, measuring 1.8mm x 5mm in length composed of titanium alloy while the arches are composed of nickel-titanium

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Extensive Bone/Implant interface on both the shaft and arch, mineralized bone has grown toward the suture and resulted in a bone gap small than the diameter of the anchor shaft. Fields RT, Wolford. J Oral Maxillofac Surg 2001:59:1402-1406

Pre-operative considerations for placement of Mitek implants

• MRI should be taken preoperatively to evaluate the condition of the disc.

• Surgical intervention should occur within the first 4 years of symptom onset to prevent permanate decrease in joint space.

• Mehra P, Wolford LM. BUMC Proceeding. 2001:14:22-26

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MRI • Open Closed

Internal derangement of the right TMJ with anterior displacement

of the articular disc without reduction.

PRINCIPLES AND PRACTICE

OF TMJ PROCEDURES:

• Surgical Technique of Mitek Placement

Photo Courtesy of Brennan Rimer and Journeys Unforgettable

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Surgical Considerations

Photo Courtesy of Brennan Rimer and Journeys Unforgettable

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• Adequate release of the anterior, lateral and sometimes medial attachments of the articular disc are usually necessary to allow passive repositioning.

• Control the occlusion in the post-surgery phase to avoid overloading the joints.

• If the disc shows severe degeneration with bony changes on the condylar head, success of Mitek implant drops from the 90th percentile to the 60th percentile.

• 52 Mitek implants were placed over the last 2 years with follow up of at least 4 months

• Mean pre-surgery VAS score 6.1 where post-surgery the mean was 2.4

• Mean pre-surgery MIO was 38.1 where the mean post-surgery value was 40.9

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• In a study by Wolford et al. 78 Mitek implants were placed over a 2 ½ year period

• Mean pre-surgery VAS score 5.2 where post-surgery the mean was 1.8

• Mean pre-surgery MIO was 40.8 where the mean post-surgery value was 43.7

Wolford, Mehara. The Mitek mini anchor for TMJ disc repositioning: surgical technique and results: Int J. Ora l MaxilloFac. Surg. 2001:30: 497-503

• In a study by Gokhan et al. 12 Mitek anchors were placed in 7 patients with post operative MRI’s taken 1 year after placement

• All patients showed the articular disc in an anatomic position maintain superior and inferior joint space without compression of the bi-laminar zone.

• Cokhan et al. Eva luation of temporomandibular joint disc-repositioning surgery with Mitek mini anchores: National Journal of Maxillofacial surgery, 4,188-

192, 2013.

• The use of Mitek anchors – 1) Provides controlled mandibular translation while

preventing mandibular condylar dislocation

– 2) Relatively straight forward technique with predictable results with decreased pain and increased MIO

– 3) Short term results (range 4 months to 2 years) show no failures however the longevity of this technique is unknown

– 4) Superior and Inferior joint space is maintained which appears to be important for allowing patients to return to normal function

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Total Joint Replacement

Disclosure

• I have no financial relationships to disclose.

• I will not discuss off label use and/or investigational use in my presentation

Condylar Resorption

Definition: • Head of condyle resorbs partially or completely

– Results in: • Loss of vertical dimension of condyle

• Often creates occlusal and musculoskeletal instability

• Dento-facial deformities

• TMJ Dysfunction

• Pain

Causes of Condylar Resorption: • Local factors

– Internal Derangement, osteoarthritis, avascular necrosis, traumatic injuries, Bruxism, ICR

• Systemic Factors – Rheumatoid arthritis, scleroderma, SLE, Ankylosing Spondylitis,

Hormones, Steroids, Systemic and Autoimmune illness

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Causes of Condylar Resorption

Pathophysiology of Condylar Resorption:

• Results from dysfunctional articular remodeling due to :

– Excessive or sustained physical stress to the TMJ articular structures that exceeds the normal adaptive capacity (Occlusal therapy, Internal derangement, parafunctional habits, Macrotrauma, Unstable occlusion), or..

– Decreased adaptive capacity of the articulating structure of the joint (Rheumatoid arthritis, scleroderma, SLE, Ankylosing Spondylitis, Age, Hyperparathyroidism, Corticosteroid therapy, Hormones such as Estrogen and Prolactin)

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Idiopathic Condylar Resorption

Also Known As:

• Cheerleaders’ syndrome

• Idiopathic condylossi

• Progessive Condylar Resporption

• Condylar Atrophy

• Predilection:

• Female 9:1

• Onset usually age 10 – 40

– Often During pubertal growth spurt

Unstable Occlusion as Etiology

Morphologic associations: • Class II skeletal and occlusal relationship • High occlusal plane angle • High mandibular plane angle Suggested Etiologies: • Excessive force on condyle

– Parafunctional habits – Orthognathic surgery – Orthodontics – Trauma

• Poor bone quality • Decreased blood supply to condyle

Hormones as an Etiology

Increased Estrogen Receptor Theory

• Estradiol 17b deficency

– Study by Gunnerson

• 26 females started on EE (ethynl estradiol) – Oral Contraceptive

• 19 patients noted occlusal changes within 1 month

• Symptomatic TMJ joints have 5 times more Estrogen receptors

• Upregulation of receptors likely to be caused by estradiol 17b deficency

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Etiology

Increased Estrogen Receptor Theory • Exaggerated estrogen response to excessive joint loading

– Trauma – Parafuntional habits – Orthodontic treatment – Orthognathic surgery

• High estrogen response leads to – Synovial tissue hyperplasia – Damages to ligamentous structures – Anterior disc displacement – Destructive hyperplastic synovial tissues surrounds condyle – Resorption of the condyle

• Rate of about 1.5mm a year

Diagnosis

Patient History • Worsening occlusion • Increased TMJ symptoms

– 25% had no TMJ issues according to Wolford.

• Worsening of class II relationship • Anterior Open Bite • Unilateral or Bilateral • Rule out systemic causes Imaging • Panograph, Lateral cephalometic, CBCT, CT, MRI

• Anteriorly displaced disk • Small resorbing condyle • Poorly defined cortex • Decreased vertical height of ramus

Diagnosis

Active vs. Inactive:

• Technetium isotope bone scan

– Technetium-99m methylene diphosphonate (99mTc-MDP)

– Kaban & Colleagues set normal values of mandibular uptake

• Active Condylar Resorption – 2 standard deviations above normal uptake

– Serial Bone scans confirm when resorption has become inactive

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Diagnosis

Palliative Management

Treatment Options in Active Phase:

• Defer Surgical Treatment until ICR Remission, at least 6 months and until patient is pain free

• Splint Therapy to “Unload Joint”

• TMJ Arthrocentesis/Arthoscopic lysis & lavage

Surgical Management

Goal of surgical intervention:

• Restore Vertical Ramus Height

• Stabilize TMJ

• Restore Occlusal Function

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Palliative Management

Treatment Options in Active Phase:

• Defer Surgical Treatment until ICR Remission, at least 6 months and until patient is pain free

• Splint Therapy to “Unload Joint”

• TMJ Arthrocentesis/Arthoscopic lysis & lavage

Surgical Management

Goal of surgical intervention:

• Restore Vertical Ramus Height

• Stabilize TMJ

• Restore Occlusal Function

Surgical Management

Treatment Options:

• Disc repositioning with stabilization

– Only possible when disc is salvageable

– Suture disk to bony anchor

– removal of hyperplastic synovial tissue

– Simultaneous Bimax Orthognathic surgery

• Orthognathic Surgery Alone

– When Condyle is completely resorbed

• Distraction Osteogenesis

– May put excessive forces on condyle

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Surgical Management

Treatment Options:

• Condylar Replacement

– Autogenic graft

• Autogenous Costochondral graft

– Total Joint Prosthesis

• Biomet Microfixation

• TMJ Concepts

Preauricular Approach to the Temporomandibular Joint

Marking the Incision

• Incision at junction of facial skin and helix

• Use skin fold

• If fold not present, digital palpation will enhance crease

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Marking the Incision

• Mark crease

• Extends superiorly to top of helix

Preparation of the Surgical Site

• Expose entire ear & lateral canthus

• Shaving preauricular hair is optional

• Clear drape to keep hair out of field

• Mineral oil or bacitracin soaked cotton in EAC

Skin Incision

• Incision made through skin & subcutaneous connective tissues, including temporoparietal fascia, to superficial layer of temporalis fascia

• Cauterize bleeders

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• With flap retracted anteriorly, oblique incision made through outer temporalis fascia

• Incision from root of arch in front of tragus, anterosuperiorly to the upper corner of the retracted flap

Dissection to the TMJ Capsule

• The temporal fat pad is exposed

• On the bone incise through the superficial layer of the temporalis fascia and the periosteum


• Dissect inferiorly to the superolateral aspect of the zygomatic arch and elevate the periosteum from the lateral surface of the arch

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• This vertical incision is made through the intervening tissues just in front of the external auditory meatus, to the depth of the protective instrument


• The entire flap is retracted anteriorly and blunt dissection continues to expose the eminence and the entire TMJ capsule

• Manipulate the mandible open & closed to help locate the articular space

Exposing the Interarticular Spaces

• Vasoconstrictor-containing solution like LA with epinephrine can be injected into the superior joint space to facilitate the surgery

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• The incision is carried posteriorly through the capsule along the lateral aspect of the fossa until the capsule blends with the posterior attachment of the disk


• Lateral retraction of the disk exposes the inner portion of the superior joint space

• The forceps are grasping the lateral wall of the lateral recess of the superior disk space

• The inferior joint space entered with scissors or scalpel incising the medial wall of the lateral recess of the superior joint space

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Superior Joint Space

• The superior joint space is closed by suturing the remaining temporal capsule attachment to the condylar capsule

• Permanent or slowly absorbing suture

Inferior Joint Space

• Irrigate joint spaces thoroughly & control hemorrhage prior to closing

• The inferior joint space is closed by suturing the disk and the lateral condylar attachment

Closure • No suture deeper than subcutaneous tissues is required

• Subcutaneous: 4-0 polyglactin (Vicryl)

• Skin: 5-0 polypropylene (Prolene) or Subcuticular: 5-0 Poliglecaprone (Monocryl)

• Pressure dressing & posterior ear bolster

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Surgical Management

Orthognathic Treatment Case Report:

• 23 y/o female

• Reports trauma to mandible years earlier

• Presents with Anterior Open Bite

• Radiographic evidence of condylar resorption

• Ruled out potential systemic causes

• Patient did not want Joint replacement

• Planned procedure BSSO

Pre Operative Photos

Pre Operative Imaging

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Pre Operative Imaging

Post Operative Imaging

Before & After

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Before & After

Before & After

Surgical Management

Why Orthognathic?:

• Patient did not want TMJ surgery

• Patient’s disc was not salvageable

• Treat Anterior Open bite with BSSO

• Entire condyle had been resorbed

– Active resorption will not return

• Patient has had no relapse of anterior open bite since surgery, no TMJ pain

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Surgical Management

Stock Total Joint Replacement Treatment:

• 53 y/o male

• Reports Orthodontic Treatment as an adult

• Worsening Anterior Open Bite

• Worsening TMJ pain

• Radiographic evidence of inactive condylar resorption

• Ruled out potential systemic causes

• Planned procedure Bilateral Total Joint replacement

Pre-Operative Photos

Pre-Operative Imaging

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Pre-Operative Imaging

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Before & After

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Surgical Management

Why Total Joint Replacement?

• Patient had worsening TMJ pain

• Patient’s disc was not salvageable

• Must increase vertical height of ramus to correct Anterior Open Bite

• Since Surgery Patient has no pain, no relapse of Anterior Open Bite, MIO of 40mm

Surgical Management

Custom Total Joint Replacement Treatment:

• 50 yo female presents for continual bilateral TMJ pain x 20 years. Patient reports history of trauma. She reports having arthrocentesis with no resolution many years ago and also orthognathic surgery in hopes to correct her bite and TMJ pain also no result.

• PMH: hyperlipidemia, bipolar disorder, TMD, PTSD,

• PSH: hysterectomy, BSSO, arthrocentesis, bladder resuspension

• SH: +tobacco 30 pack years- quit recently

• Meds: alprazolam, buproprion, buspirone, gabapentin, laotrigine, naproxen, risperidone, premarin, sertraline, zolmitriptan

• Allergies: codeine, lithium, sulfa, sumatriptan

• Diagnosis: osteoarthritis of bilateral TMJ, internal derangement of the bilateral TMJ

• Procedure: bilateral total joint replacement of the TMJ

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Custom TMJ replacement

• Definitive Surgery for JP

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TMJ Concepts

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Conclusion

• Type of Surgical Intervention for ICR should be considered case by case based upon:

– Patient’s History

– Active vs inactive resorption

– Ability to salvage Disc

– Amount of condylar resorption

– Patient Preference

• Appropriate Surgical Treatment should then be initiated

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Reconstruction of TMJ with costochondral rib graft

• Age: 13

• Gender: Female

• CC: “ I can’t open my mouth wide”

• HPI: h/o seizure fall at age 6

progressive restriction in opening

• PMH: Systemic Lupus Erythematosus

• Exam: Inter-incisal opening 8mm

left mandibular deviation

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References

• Arnett GW, Milam SB, Gottesman L: Progressive mandibular retrusion—Idiopathic condylar resorption. Part II. Am J Orthod Dentofac Orthop 110:117, 1996.

• Larry M.Wolford, Luis Cardenas: Idiopathic condylar resorption: diagnosis, treatment protocol and outcomes. Am J Orthod Dentofacial Orthop 1999;116:667-77

• Chung CJ, Choi YJ, Kim IS, Huh JK, Kim HG, and Kim KH. Total alloplastic temporomandibular joint reconstruction combined with orthodontic treatment in a patient with idiopathic condylar resorption.

• Wolford LM: Idiopathic condylar resorption of the temporomandibular joint in teenage girls(Cheer leaders syndrome). Proc(Bayl Univ Med Cent) 2001;14:246-52

• Gala N, El Beialy W, Deyma Y, Yoshimura Y, Yoshikawa T, Suzuki K, et al. Effect of estrogen on bone resorption and inflamation in the temporomandibular joint cellular element. Int J Mol Med 2005;15:827-32

• YL, Pogrel MA, Kaban LB: Diagnosis and management of condylar resorption. J Oral Maxillofac Surg 55:114, 1997

• Mercuri LG. A rationale for total alloplastic temporomandibular joint reconstruction in the management of idiopathic / progressive condylar resoprtion. J Oral Maxillofac Surg 65:1600-16.9,2007

• You, Yang, and Hwang. Idiopathic Condylar Resorption. J Oral Maxillofac Surg 2010. j.joms.2010.01.012

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arthrocentesis and arthroscopy · patients diagnosed with tmj disease: when is surgery indicated ?...

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