Procedures

Intermediate FormatTemporomandibular Joint

Arthroscopy

Objectives• Assess the related terminology and

pathophysiology of the TMJ.• Analyze the diagnostic interventions for a

patient undergoing a _______________.• Plan the intraoperative course for a patient

undergoing_____________.• Assemble supplies, equipment, and

instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for TMJ

Arthroscopy.• Describe the care of the specimen

Terms and Definitions

• Bruxism• Malocclusion

Definition/Purpose of ProcedureTemporomandibular Joint (TMJ)

Disorder occurs when the muscles used in chewing and the joints of

the jaw fail to work in combination with each other.

A & P : TMJ

Pathophysiology

Causes: Bruxism, Malocclusion, Arthritis,

Trauma

Pathophysiology

Signs & SymptomsPain, clicking, limited range-of-

motion, spasms, asymmetry

Diagnosis

Linear CT and MRI

Treatment

• 5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery

• Antiinflammatories, soft diet, hot compresses, muscle relaxants

• >2 weeks: intraoral occlusion splints, med tx• Recurrent or chronic: permanent dental correction

Surgical Intervention:Special Considerations

• Patient Factors– Outpatient– H& P, Blood chemistries, CBC, PT, PTT, U/A,

serum HCG, Chest x-ray or ECG as appropriate• Room Set-up

– X-rays in room

Surgical Intervention: Positioning

• Position during procedure– Supine w/head donut pillow, tuck arms to side

• Supplies and equipment– Arm sleds, headring pillow

• Special considerations: high risk areas– Elbows—ulnar nerves

• Prep– Shave preauricular area– Cotton to ears to prevent pooling of povidone-iodine & caution

w/eyes; entire facial area prepped from hairline, down to shoulder, and laterally to include mouth and chin

Surgical Intervention: Special Considerations/Incision

• Special considerations– Nasal intubation– Prophylactic antibiotics & steriods

• State/Describe incision– Small stab incision w/# 11 before trocar is

introduced at superior joint space

Surgical Intervention: Supplies

• General: basic pack drape and split head sheet, gowns & gloves, towels, basin set, prep set, sterile adhesive wound drape, irrigation pouch, skin marker, raytex,

• Specific– Suture & Blades (# 11)– Medications on field (name & purpose)– Catheters & Drains: n/a– Drapes: head turban for initial drape; pad pt forehead with a

folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)

Surgical Intervention: Supplies cont’d

• 2 60 mL syringes• 4 10 mL syringes• 1 1-mL syringe• Needles: 18 g, 21 g, 25 g• Skin stapler• Eye pads• Sterile water and saline• 1000 mL Lactated Ringers for irrigation• 30 in extension tubing• Stopcock

Surgical Intervention: Instruments

• General: suction, Lactated Ringer’s IV bag for irrigation, marking pen

• Specific– TMJ instrument set

• 0 degree arthroscope• 30-degree arthroscope• 70-degree arthroscope• Cannulas• Sharp & dull obturators

– Light cord, camera & cord, small joint rotary shaver

Surgical Intervention: Equipment

• General: suction system

• Specific– Monitor/light source/camera tower, shaver control unit,

IV pole for irrigant– Fluid infusion system– Bipolar ESU– Holmium laser

Surgical Intervention: Procedure Steps

• Irrigation solution is injected into the joint space to distend the capsule– LR solution is preloaded in syringe w/needle attached.

• After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures. – #11 blade with # 7 handle will be ready– Trocar/cannula is preassembled. Expect trocor to be returned. Be

prepared to assist with connections of video/light cord connections.

Surgical Intervention: Procedure Steps

• Irrigation is infused into the joint– LR solution is connected to the cannua via extension

tubing• Joint is examined

– Prepare to operate remote control for still photos• If functional surgery is needed, a second stab wound is

made– Pass skin knife. Prepare additional equipment (probe, shaver,

grasper)

• Final visual inspection is performed– Additional photos may be taken

Surgical Intervention: Procedure Steps

• Cannuale are removed and excess fluid removed– Prepare for closure; count

• Wound is closed and dressing placed– Pass suture; prepare dressings, reorganize

equipment & supplies if procedure is bilateral• Steps may be repeated contralaterally

– Repeat steps

Counts

• Initial: sponges and sharps• First closing• Final closing

– Sponges– Sharps

Specimen & Care

• Identified as n/a or as specified (eg chondromalacia)

• Handled: routine, etc.

Postop Considerations

• Immediate– ROM of jaw limited– Suction and Emergency airway supplies readily

available; Elevate HOB 30 degrees– Ice for pain and swelling– Liquid or soft diet for several days

• Prognosis: good—may recur if behaviors not resolved; PT may begin in 24-48 hrs post-op.

• Complications: hemorrhage, infection, recurrence– Joint damage, destruction of middle ear ossicles, perforation into

middle cranial fossa, injury to auriculotemporal nerve

Resources

• www.healthscout.com• STST pp. 646-647, Procedure 18-7• www.dentaljournal.com/article 6• Rodau; Baker-Gill, Levin; “Arthroscopic

Temporomandibular Joint Surgery”, AORN Journal Nov 1993, 58: 5.