899 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE * AS MINI NCORAS COMO ALTERNATIVA PARA O TRATAMENTO DA LUXAO RECIDIVANTE DA ATM E DO DESLOCAMENTO DO DISCO SEM REDUO REVISTA DA LITERATURA E RELATO DE CASO CLNICO-CIRRGICO Juliana Maria SOUZA DE OLIVEIRA ** Marcos Maurcio CAPELARI *** Clvis MARZOLA **** Joo Lopes TOLEDO FILHO ***** Gustavo Lopes TOLEDO ***** Daniel Luiz Gaertner ZORZETTO ***** Cludio Maldonado PASTORI ***** Marlia GERHARDT DE OLIVEIRA ****** ___________________________________ *PresentedasapartialrequirementoftheDepartmentofEducationandResearch MethodologyforthetitleofSpecialistinMaxillofacialTraumatologySurgeryfromthe Federal Council of Dentistry. **SpecializingandResidentfromtheCourseofSurgeryandMaxillofacialTraumatologyfrom Regional APCD from Bauru and Base Hospital at Hospital Association of Bauru. ***ProfessoroftheCourseofSurgeryandMaxillofacialTraumatologyfromRegionalAPCD fromBauruandadvisorinthisStudy.HolderMemberofTiradentesAcademyof Dentistry and the Brazilian College of Surgery and Maxillofacial Traumatology. ****ProfessoroftheCourseofSurgeryandMaxillofacialTraumatologyfromRegionalAPCD fromBauru.PresidentofTiradentesAcademyofDentistryandChiefEditorofthe JournalofDentistryATO.MemberoftheBrazilianCollegeofSurgeryand Maxillofacial Traumatology and the Brazilian Academy of Dentistry. *****TeachersoftheCourseofMaxillofacialTraumatologySurgeryatRegionalAPCDfrom Bauru. Full Members of the Brazilian College and Maxillofacial Traumatology Surgery. ****** Titular Professor of Surgery of the PUC-RS University Porto Alegre, RS, Brazil. 900 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE ABSTRACT Thetemporomandibularjointisoneofthemostcomplexand importantjointsinthehumanbody.Becauseithasanintensedynamic,the disharmonyandimbalancebetweentheircomponentsgenerates temporomandibulardisorders,amongwhichthemandibulardislocationand displacementofthediscarethemostcommon.Thisstudyisvaluablefor raisingimportantissuesrelatedtotemporomandibularjointandthetechnique fortreatmentofchronicrecurrentmandibulardislocationwithanterior displacementofthearticulardiscwithoutreduction,usingdiscopexy endosseousdevicessuchasminianchors,showingthemainadvantages, disadvantages, indications, contraindications and possible complications related totechniqueandthereportingofcasewherethesurgicaltechniquewas applied. RESUMO Aarticulaotemporomandibularumadasarticulaesmais complexas e importantes do corpo humano.Por possuir uma intensa dinmica, adesarmoniaedesequilbrioentreseuscomponentesgeramdesordens temporomandibulares,destacando-sealuxaomandibularedeslocamentos dodiscoarticular.Opresenteestudoreveste-sedegranderelevnciapor revisaraspectosimportantesrelativosArticulaoTemporomandibularea tcnicaparatratamentodaluxaomandibularcrnicarecorrentecom deslocamento anterior de o disco articular sem reduo, atravs da discopexia utilizandodispositivosendsseos.Asminincorassoutilizadas,mostrando asprincipaisvantagens,desvantagens,indicaes,contraindicaeseas possveis complicaes referentes tcnica, alm do relato de um caso clnico cirrgico onde a tcnica foi aplicada. Unitermos:Articulaotemporomandibular;Discodaarticulao temporomandibular; Sistema Estomatogntico. Uniterms:Temporomandibularjoint;Temporomandibularjointdisk; Stomatognathic system. INTRODUCTION Thetemporomandibularjoint(TMJ)isoneofthemostcomplex and important joints of the human body and, together with the maxillary bones, glandsandnervesmakeupthestomatognathicsystem(GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007; MARZOLA, 2008 and NUNEZ BALDERRAMA; TOLEDO; TOLEDO-FILHO et al., 2010). Byhavinganintensedynamicdisharmonyandimbalance betweeniscomponentsgeneratetempomandibulardisorders(TMD), emphasizingthemandibulardislocationanddisplacementofthedisc (GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO,2007;MARZOLA,2008andTAVARES;TAVARES;DIAS-RIBEIRO, 2010). 901 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Theetiologyoftemporomandibulardisordersismultifactorialand maybeassociatedwithseveralfactors(TOMACHESKI;BARBOZA; FERNANDES et al., 2004; GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and MARZOLA, 2008). ThesceneryofdislocationoftheTMJmaybetheresultof mandibular hypermobility. When the episodes become frequent, this condition is calledrecurrent,maybeassociatedwiththeinclinationdegreeofthearticular eminence(VASCONCELOS;CAMPELLO;OLIVEIRAetal.,2004e GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO, 2007 and MARZOLA, 2008). Thisdisorderischaracterizedbyexcessivetranslationofthe condyle, which exceeds the previous anatomical articular eminence (ARAJO; GABRIELLI;MEDEIROS,2007;GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and MARZOLA, 2008). Thereturnofthemandibularcondyletoitsanatomicalposition may be complicated by anterior displacement of the articular disc. The condyle cannotovercomethediskgeneratingasubsequentlimitationinmandibular movements(ARAJO;GABRIELLI;MEDEIROS,2007;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007and MARZOLA, 2008). Chronicrecurrentmandibulardislocationand/oranterior displacementofthearticulardisccanbetreatedwiththeaidofendosseous devicessuchasminianchorsforthecorrectrepositioningandfixationofthe articulardisconthecondyleandfixationofafixedstructureofthecranium (WOLFORD; PITTA; MEHRA, 2001 and LOBO LEANDRO, 2007). Thepurposeofthesedevicesistorestrictandcontrolexcessive movement of the mandibular condyle, and enhance the action of the ligaments thatare unstable,preventing further episodesof dislocation, anddisplacement of the disk of is usual anatomical position (WOLFORD; PITTA; MEHRA, 2001 and LOBO LEANDRO, 2007). Thispaperaimstoreviewimportantaspectsofthe TemporomandibularJointandthetechniquefortreatmentofchronicrecurrent mandibulardislocationwithanteriordisplacementofthearticulardiscwithout reduction by discopexy using endosseous devices such as mini anchors. Will be shown the main advantages, disadvantages, indications, contraindications, and possible complications related to technique. It will also be shown the report of a casewherethissurgicaltechniquewasapplied.Itisofimportancesucha study,giventheshortageofstudiesthatdiscussthistechniqueinthecurrent literature, and of course, todays theme LITERATURE REVIEW ANATOMY OF TEMPOROMANDIBULAR JOINT Thetemporomandibularjoint(TMJ)iscomplexregionofthe maxilofacialskeleton,composedofthetemporalboneandmandible,a specializeddensefibrousstructure,thearticulardisc,variousligamentsand musclesassociatedwithnumerous,allowingfreemovementsandcomplexon the articular surfaces (ARAJO; GABRIELLI; MEDEIROS, 2007; GERHARDT 902 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE DEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007 and MARZOLA, 2008). Itisajointbilateral,interconnectedandinterdependentbythe lowerjaw,withpropermotionsforeachside,butconcurrent,andmaybe classifiedanatomicallyindiartrodialarticulation,anarticulationoftwobones discontinuous(MADEIRA,2004;ARAJO;GABRIELLI;MEDEIROS,2007; GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO,2007;MARZOLA,2008eMILORO;GHALI;LARSENetal., 2008). BONE STRUCTURES The bones that comprise the ATM are the head of the mandible or condyle, articular eminence and mandibular fossa of the temporal (ZORZETTO, 2003) (Figure 1). Figure 1 Bone structures. Source Figure taken from the internet page: http://www.drpaulocoelho.com.br/dtm-dor-orofacial/. Thearticularfosseormandibularislocatedinthesquamous temporal,beforethetympanicbone(BADIM;BADIM,2002;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007and MARZOLA,2008).Presentsformatovalandconcavewithawidthof approximately23mmandthetransverseportion19mminthesagittal (MOLINA,1995).Itisrecoveredbyfibrocartilaginuostissuecontaininginits previouslimitthearticulareminence(FAVERO,1999;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007and MARZOLA, 2008). 903 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Thearticulareminenceisaboneproeminencetransverse continuous through articular surface and is distinct from the articular tubercle, a processnotarticulatetherootofthezygomatictemporalbone,servingasthe pointofinsertionofthecollateralligaments(GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007; MARZOLA, 2008 and MILORO; GHALI; LARSEN et al., 2008). ThemandibleboneisaU-shaped,whicharticulatedwiththe temporal bone through its condyles, which have an elliptical shape with convex and approximate size of 15-20 mm in the lateral-medial portion and 8-10 mm in sizeanteroposterior(MADEIRA,2004;ARAJO;GABRIELLI;MEDEIROS, 2007;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO,2007;MARZOLA,2008andMILORO;GHALI;LARSENetal., 2008). The pterygoid fovea, a depression prominently situated below the articular surface of the mandible is the site of insertion of the pterygoid muscle (GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO,2007eMARZOLA,2008andMILORO;GHALI;LARSENetal., 2008). ARTICULAR DISK Thearticulardiskconsistsofdensefibrousconnectivetissue, avascular and not innervated, allowing it to resist pressure (ZORZETTO, 2003) (Figure 2). Figure 2 Articular disk. Source - NETTER, F. H. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000. 904 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Has a concave shape in the bottom and convex at the top, whose configuration accommodates the convexity of the condyle, the concavity of the eminence and mandibular fossa, even when the jaw assumes various positions (ASH;RAMFJORD;SCHMIDSEDER,2007;GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007; MARZOLA, 2008 and MILORO; GHALI; LARSEN et al., 2008). Thesagittalsectionisnotedinthe formatScan be dividedinto threebands,theanteriorband,intermediateandposteriorband(FREITAS, 2006;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007and MARZOLA, 2008). Theintermediatezoneisthinnerandisusuallythefunctionarea betweenthemandibularcondyleandtemporalbone.Thediskisflexibleand adaptstofunctionaldemandsofthearticularsurfaces(ASH;RAMFJORD; SCHMIDSEDER, 2007 and GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007). Divides the joint into two compartments, the upper and lower disk aboveorbellowthediskand,fitsaroundthejointcapsule(ARAJO; GABRIELLI; MEDEIROS, 2007). The bottom compartment allows sliding movement or rotation, and thus called ginglimide, while the top compartment allows sliding movement or translation, and called artrodial and, therefore, the temporomandibular joint can beclassifiedginglimoartrodial(GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007 and MILORO; GHALI; LARSEN et al., 2008). Thediskisalreadyinsertedintheperipheryofthearticular surfacesofthecondyleandeminence.Also,isinsertedintothemasseter, temporalis and lateral pterygoid muscles, and posteriorly bilaminar zone (ASH; RAMFJORD;SCHMIDSEDER,2007andGERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007). The fibers of the upper head of lateral pterygoid muscle which fall within the disc in its medial aspect apparently have the function of stabilizing the discinthemandibularcondyleduringfunction(GERHARDTDEOLIVEIRA; MARZOLA;BATISTAetal.,2007andMILORO;GHALI;LARSENetal., 2008). The ligaments of the condyle allow the stabilization by preventing thedisctomovebackwardsandupwardswhenthejawhassufferedalarge pressure.Thediskligamentsarefibroelastics,vascularizedandinnervated, especially in the zone posterior bilaminar.The main functions of the disk are to actas protectorofthebonyareasduring movement,cushioningthemandthe possible shocks (FREITAS, 2006 and GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007). TISSUE RETRODISCAL Thebilaminarzoneortissueretrodiscalisanareaofloose connective tissue highly vascularized and innervated (OKESON, 1992). Thesuperioraspectretrodiscaltissuecontainselasticfibersand collagen, fat and vessels.The bottom is composed of collagen fibers strained.Theposteriorportionofdiscistheconfluenceofbothaspects(BUMANN; LOTZMANN, 2002 and GERHARDT DE OLIVEIRA; MARZOLA;BATISTA et al., 2007). 905 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Asopposedthedisk,thebilaminarzonecanbeeasily compressed, having its surface modified by making it suitable for a proper joint (ISBERG, 2005 and GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007). JOINT CAPSULE AND SYNOVIAL MEMBRANE Thejointcapsuleandsynovialmembranehavethefunctionof coat the inner aspect of the temporomandibular joint.The space formed by the unionofthesetwostructuresiscalledthesynovialcavity,filledwithsynovial fluid(GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007and MILORO; GHALI; LARSEN et al., 2008). Withthefunctionofproducingsynovialfluidhasthesynovial membrane,vasculartissuecomprisesathin,soft,andrichlyinnervated (FREITAS,2006andGERHARDTDEOLIVEIRA;MARZOLA;BATISTAet al., 2007). The synovial membrane has villi that can be found in the anterior and posterior borders of the articular cavity, giving flexibility to the inner face of thecapsuleand,allowingauniformdistributionofthesynovialfluid (BIASOTTO-GONZALEZ,2005andGERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007). Synovialfluidhasthefunctionofperformingthelubricationand nutritionoftheATM,reducingthefrictionbetweenbonystructures,protecting thecartilagecells,andthecompletionofphagocytosisofparticulateinducts.The viscosity of this liquid can be changed before some infection, inflammation, hemarthrosis.Withthedecreaseofviscosity,articularcartilagecanbecome vulnerabletodegradativeenzymesinitiatingdegenerativeprocesses (BIASOTTO-GONZALEZ,2005andGERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007). LIGAMENTS The ligaments of the TMJ are composed of connective tissue rich incollagenfibers.Actpassivelyrestrictingmovement,andofferingprotection forstructures.Areinnervatedandmayhaveafunctionproprioceptive (FREITAS,2006andGERHARDTDEOLIVEIRA;MARZOLA;BATISTAet al., 2007). Five are the ligaments of the TMJ, functional three ligaments that hold the side, and temporomandibular capsule and ligaments two accessories, and sphenomandibular estilomandibular (OKESON, 1992) (Figure 3). The collateral ligaments are attached to two poles in the disc and condyle.Ligaments are intra capsular and further stabilization of the disc on the condylearticular duringthe movementsoftranslationandrotation ofthe ATM, restrictingthemovementofthedisk(BIASOTTO-GONZALEZ,2005and GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007). The capsular ligament involves the entire joint, uniting superiorly to thetemporalbonealongtheedgeofthemandiblefosseandeminence,and inferior to the condylar head along the edge of the facet joint (GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and MILORO; GHALI; LARSEN et al., 2008). 906 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 3 Ligaments of the temporomandibular joint. Source: NETTER, F. H.. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000. Theroleofthecapsularligamentistoresistanyforcemedial, lateral or lower that tends to separate or move the articular surfaces and, thus keepingthejointtogether.Asecondaryfunctionistocontainthecapsular ligamentsynovialfluidspaceswithintheupperandlowerhinge(BIASOTTO-GONZALEZ,2005andGERHARDTDEOLIVEIRA;MARZOLA;BATISTAet al., 2007). Theligamenttemporomandibularlimitsopeningextentof rotationalmovementandposteriorcondyleandthedisk.Retrodiskaltissues protectsfromthetraumacausedbyposteriordisplacementofthecondyle (OKESON,1992andGERHARDTDEOLIVEIRA;MARZOLA;BATISTAet al., 2007). Theligamentsphenomandibularnothaveanylimitingeffecton mandibularmovement,whiletheestilomandibularlimitsprotrusivemovements ofthejaw(FREITAS,2006andGERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007). Thesphenomandibularligamentemergesfromthespineofthe sphenoid bone in the cleft petrotympanic, down to its insertion in the lingula of themandible.Thisligamentservessomewhatasapointofrotationforthe activation of the lateral pterygoid muscle, thus contributing to translation of the jaw (MILORO; GHALI; LARSEN et al., 2008). The stylomandibular ligament is inserted above and subsequently on the styloid process and inferiorly on the angle and the posterior portion of the internalmandibleramous(MOLINA,1995).Itworksbypreventingexcessive movementofprotrusionofthemandible(BIASOTTO-GONZALEZ,2005and GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007). MUSCLES Musclestraditionallyregardedasthemusclesofmasticationare thetemporal,masseter,themedialpterygoidandlateralpterygoid(Figure4 907 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE and5)(SICHER;DUBRUL,1977andGERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007). Figure 4 Aspect of the temporalis and masseter muscles in lateral. Source: NETTER, F. H. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000. Figure 5 Aspect of the medial and lateral pterygoid muscles. Source: NETTER, F. H. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000 The pairs of temporal muscles, masseterics, pterygoid medial and havethefunctionpredominantlyelevationofthemandible,whilethepterigoid lateralhasthefunctiondepressant(MADEIRA,2004andGERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007).Othermusclesinvolvedin mandiblefunctionindirectly,suprahyoidandinfrahyoidmuscles.Thesupra hyoidmusclesadheretothehyoidboneandthemandible,assistinginthe loweringofthemandible.Theinfrahyoidbonefixedduringmovements depressiveofthemandible(MOLINA,1995andGERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007). 908 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE VASCULARIZATION AND INNERVATION Thevascularsupplyisprovidedbythesuperficialtemporaland maxillary arteries in the posterior and the anterior portion of the lateral pterygoid andmassetericbranches(SICHER;DUBRUL,1977andGERHARDTDE OLIVEIRA; MARZOLA; BATISTA et al., 2007) (Figure 6). Figure 6 Temporal and maxillary arteries with its branches. Source:SOBOTTA,J.Atlasdeanatomiahumana.18ed.RiodeJaneiro:Ed. Guanabara/Koogan, 1990. Avenousplexusislocatedintheposterioraspectofthe articulationassociatedwiththeretrodiscaltissues,whicharealternatelyfilled andemptiedwiththeprotrusiveandretrusivemovements,respectively,ofthe condyle-disccomplexandalsoassistintheproductionofsynovialfluid(GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and MILORO; GHALI; LARSEN et al., 2008) (Figure 7). 909 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 7 Venous plexus. Source: NETTER, F. H. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000. Theprincipalresponsibleforinnervatingareaurculotemporals andmasetericsnerves,bothoriginatedfromthemandibularbranchofthe trigeminal nerve, the sensory branch of the facial nerve and to a lesser extent, the chorda tympani nerves (GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and PAIVA, 2008) (Figure 8). Figure 8 InnervatingSource: NETTER, F. H. Atlas de Anatomia Humana. 2ed. Porto Alegre: Ed. Artmed, 2000. 910 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE DISORDER TEMPOROMANDIBULAR JOINT Thetemporomandibulardisorders(TMD)canbedefinedasa changeinthestructuresofthemasticatorysystem,wheretheTMJisnot physiologically balanced than its ability to tolerance, adaptability and remodeling (OKESON,2000;STECHMANNETO;FLORIANI;CARRILHOetal.,2002; GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007andLOBO LEANDRO, 2007). ThesignsandsymptomsmostcommonlyassociatedwithTMD arepaininthetemporomandibularjoint,paininjawopeningandclosingwith restrictionorlimitationinmovement,facialpain,spasmandmusclepainon palpation,crepitationorpopping,painorringingear,neckpain,headache, among other (GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and PAIVA, 2008). Theetiologyismultifactorialandmaybeassociatedwithvarious aspectssuchaschangesinocclusion,traumaticinjuryordegenerativeTMJ, skeletalproblems,psychologicalfactorsthatcausestressincreasedmuscular activity, causing spasms and fatigue, and parafunctional habits can be harmful andleadtheimbalanceofATMandharmonyofthewholestomatognathic system (QUINTO, 2000; GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). The temporomandibular disorder may be divided into non-articular disorders,disordersmusclespasmandmyositis,aswellasthebreakdownof articulardomesticandnon-inflammatoryarthropathies,growthdisorders,and connectivetissuedisorders(GERHARDTDEOLIVEIRA;MARZOLA; BATISTAetal.,2007;LOBOLEANDRO,2007andMILORO;GHALI; LARSEN et al., 2008). Non-inflammatorydisordersoftheTMJjointwhichisthemost commonly osteoarthritis, may manifest as chondromalacia, the loosening of the cartilage,temporaryorpermanentdisplacementofthedisc,degenerative changesoftheboneorcartilage(GERHARDTDEOLIVEIRA;MARZOLA; BATISTAetal.,2007;LOBOLEANDRO,2007andMILORO;GHALI; LARSEN et al., 2008). DISLOCATION OF THE TMJ Dislocationofthetemporomandibularjointischaracterizedby abnormalpositionofthecondyleinrelationtothejointcavity,whereittakes place below the articular eminence without returning to its rest position, locking thejawopen.Thistablecanbetheresultofmandibularhypermobilityand injuryofthecapsuleleadstospasmsofthejawmuscles,especiallythe elevators (SICHER; DUBRUL, 1977; GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007) (Figure 9). The condylar displacement can cause stretching of the ligaments, whichmaybepermanent,resultingintherecurrentdislocationaggravatedby havingyoureverystretch(ALMEIDA;MARZOLA;TOLEDO-FILHOetal., 1991;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007and LOBO LEANDRO, 2007). 911 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Thedislocationcanbeunilateralorbilateralandisusually reduciblebybloodlessmaneuversiftreatedbeforetheoccurrenceofmuscle spasms ((ARAJO; GABRIELLI; MEDEIROS, 2007). Figure 9 Dislocation of the TMJ. Source:FREITAS,R.TratadodeCirurgiaBucomaxilofacial.SoPaulo:Ed.Santos,653p., 2006. Themainsignsandsymptomsoftemporomandibularjoint dislocationarethedifficultyofclosingthemouth,excessivesalivation,painin thejointregion,thepreauriculardepressionandmuscletension (VASCONCELOS;CAMPELLO;OLIVEIRAetal.,2004;TEDESCHI-MARZOLA,2005;GAIO;HEITZ;GERHARDTDEOLIVEIRAetal.,2006; GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007andLOBO LEANDRO, 2007). Thesurgicaltherapyshouldbeinstitutedfromthetimethat conservativetreatmenthadnoeffect,andpatientswithsignsandsymptoms remain chronic, with repeated episodes of dislocation, joint pain and masticatory dysfunction (MOLINA, 1995; VASCONCELOS; CAMPELLO; OLIVEIRA et al., 2004;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007and LOBO LEANDRO, 2007). 912 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE DISPLACEMENT OF ARTICULAR DISK Chronic inflammatory or degenative changes may lead to changes inthemorphologyofthediskandthearticularsurfaces(ARAJO; GABRIELLI;MEDEIROS,2007;GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Themobilityofthediskisdirectlyrelatedtotheligamentsofthe temporomandibularjoint.Thestretchingorlossofstructuralintegrityofthese ligamentsmaybeduetofactorssuchastrauma,jointspacenarrowing,the slopeofthemorphologyofthearticulareminenceandcondylearticularfosse, highinsertionoflateralpterigoidmuscle,arthritis,osteoarthritis,condylar reabsorptiondentofacialdeformities,malocclusion,inflammation,infection, compression of the bilaminar zone, parafuncional habits, and systemic diseases thatmayaffecttheTMJ(TEDESCHI-MARZOLA,2005;GAIO;HEITZ; GERHARDTDEOLIVEIRAetal.,2006;GERHARDTDEOLIVEIRA; MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007andFALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). The lack of coordination between the condyle and the disk during the translationalmovementcan be accompanied bycrackingofthejoint, most often perceived by the practitioner and patient.When not accompanied by pain andlockingofthejoint,doesnotcharacterizeapathologybackground. Howeverwhenthelockofthetemporomandibularjointispresent,themaybe aninterferenceinpreventingthecondylediskdothetranslationmovement (BADIM;BADIM,2002;TEDESCHI-MARZOLA,2005;GAIO;HEITZ; GERHARDTDEOLIVEIRAetal.,2006;GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). This disorders related to interference on the disk can be classified intofourcategories,anincoordinationofthecondyle-diskcomplex,structural incompatibilityofthearticularsurfaces,subluxation,andthespontaneous dislocation (OKESON, 1992). Theincoordinationofthecondyle-diskcomplexcanoccur stretchingofthecollateralligamentsofthediskandbladeretrodiscallower.With this stretch, the disk can be pulled completely through the disk causing the dislocationofthesamewiththecondyle,andthisconditionisknownasa slippeddisk(OKESON,1992;GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Thisdisplacementofthearticulardiskmayoccurwithorwithout spontaneousreduction.Noreductionintheanteriordislocation,thediskis located at rest before the condyle.During the opening and closing movements ofthecondylecannotexceedtheregionofthedisk,causinglimitationin mandibularmovements(ARAJO;GABRIELLI;MEDEIROS,2007; GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007andLOBO LEANDRO, 2007) (Figure 10). Whenrecapturethedisktothenormalpositionoccurs,itis consideredastheframeoffsetofthediscwithareduction.Typicallythe openingandclosingmovementsareretained,accompaniedoftenacrackdue tothepassageofthecondylarportionofthedisk(KURITA;OHTSUKA; KOBAYASHI et al., 2000). 913 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 10 Displacement of the articular disk without spontaneous reduction. Source: COLOMBINI, N. E. P.; SANSEVERINO, C. Cirurgia da face Interpretao Funcional e Esttica V. I, V. II e V. III. Rio de Janeiro: Ed. Revinter Limitada, 2002. SURGICAL THERAPY Dependingonthestageofdysfunction,themedicaltreatment itself,includingdrugtherapyandanti-inflammatorysteroids,stressreduction, physicaltherapy,devicestability,andocclusalrehabilitation,maynotresultin adequateresponseDIMITROULIS,2005;GERHARDTDEOLIVEIRA; MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007andFALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). The indications for surgery in the TMJ can be divided into relative andabsolute.Theabsoluteinvolvescasessuchastumors,abnormalitiesof growthandTMJankylosis,wheresurgeryhasindisputablerole.Incasesof relativeindication,patientsmusthavepainlocatedinmoderatetosevere dysfunctionandsignificantworseningoftheATMfunctionsprimarilyduring mandibular(DOLWICK,2007;GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Wherethereisaninternalderangementassociatedwithlackof responsetomedication,suchasrecurrentdislocationoftheTMJassociated withaseriousdisplacementofthearticulardisc,adirectapproachtothe surgicalprocedureisnecessary(LOBO;NUNES,2000;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBOLEANDRO,2007and FALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). Clinicalfeaturescommonlypresentedbypatientswhorequire surgeryarepain,masticatorydysfunction,recurrentepisodesofchronicand mandibular displacement of the articular disc without reduction, clicks, crackles, andjointhypomobility(WOLFORD;PITTA;MEHRA,2001;GERHARDTDE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Evidenceofimagesshouldbeusedtoconfirmandsupportthe clinical(DOLWICK,2007;GERHARDTDEOLIVEIRA;MARZOLA;BATISTA et al., 2007 and LOBO LEANDRO, 2007). 914 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Thesurgicaltherapyhasamongitsobjectives,restrictingthe movementofmandibulartranslationorremovethebarrierstopromotefree mandibularmovements,thuspreventingthedisplacementandlocking mandibularanteriortothearticulareminence(WOLFORD;PITTA;MEHRA, 2001;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO,2007andMOUTINHO-NOBRE;CAPELARI;MARZOLAetal., 2009). Manymethodshavebeendescribedintheliterature,including plicationofthejointcapsule,theobliqueosteotomyofthezygomaticroot (BUCKLEY;TERRY,1988),arthrocentesis(DOLWICK,1997;FROST; KENDELL,1999andGROSSMAN;GROSSMAN,2011),arthroscopy (MARTINS,1993;ISRAEL,1999andGROSSMAN;GROSSMAN,2011), eminectomy(WOLTMANN;FELIX;FREITAS,2002;CARDOSO; VASCONCELOS;OLIVEIRA,2005;PASTORI;MARZOLA;TOLEDO-FILHO etal.,2008andMOUTINHO-NOBRE,CAPELARI;MARZOLAetal.,2009), the use of mini plates in the articular eminence (CARDOSO; VASCONCELOS; OLIVEIRAetal.,2006;MOUTINHO-NOBRE;CAPELARI;MARZOLAetal., 2009 and AZENHA; SAAB; MARZOLA, 2010), and the use of mini anchors in thecondyleandtheposteriorrootofthezygomaticarchtothearticulardisc repositioning (WOLFORD; DALLAS, 1997; SEMBRONIO; ROBIONY; POLITI, 2006;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007and LOBO LEANDRO, 2007). Eachtechniquewasdevelopedforthetreatmentofseveral disorders that can affect the TMJ, with their specific indications, advantages and disadvantages,withtheultimategoalofstabilizingthesituation,remove etiologic factors and promote conditions for repair (GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and MOUTINHO-NOBRE; CAPELARI; MARZOLA et al., 2009). Theprocedureofchoiceshouldbetheonetopresentlessrisk andgreatercost/benefittosolvingthespecificproblemofthepatient (DOLWICK,2007andGERHARDTDEOLIVEIRA;MARZOLA;BATISTAet al., 2007). ARTHROCENTESIS Thetechniqueof arthrocentesisofthetemporomandibularjointis the washing of the upper joint space. It is less invasive and simpler among the other (DOLWICK, 1997; GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Itsindications,patientswithdisplacementacuteorchronic articular disc with orwithout reduction, limitation of mouth opening of articular origin,jointpain,andotherinternalderangementsofthejointthatfailedto respondadequatelytoconservativetherapy(GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and GROSSMAN; GROSSMAN, 2011). However,whenIstartthelockisacute,thebettertheprognosis forasuccessfuloutcome(DOLWICK,1997;GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). ArthrocentesisoftheTMJjointrelievessymptomsbylysisand washingofthesynovialcavity.Thus,thisproceduremayhaveabeneficial 915 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE effectonthepathologicalchangesreducedintraboneasabnormalitiesinthe bonemarrow,althoughprovidinggoodimprovementinpatientswith osteoarthritisand/orerosivechangesinthecorticalcondyle(FROST; KENDELL,1999;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal., 2007; LOBO LEANDRO, 2007 and HONDA; YASUKAWA; FUJIWARA et al., 2011). In the contraindications, patients have limitation movement as the onlycomplaintandfibrousankylosisisnotsensitivetothearthrocentesis (FROST; KENDELL, 1999; GERHARDT DE OLIVEIRA; MARZOLA; BATISTA et al., 2007; LOBO LEANDRO, 2007 and HONDA; YASUKAWA; FUJIWARA et al., 2011). The condition of interference mechanical are serious indications to performopensurgery,becausethesecasesarerarelysuccessfulwith arthrocentesis(DOLWICK,2007;GERHARDTDEOLIVEIRA;MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Traditionally,thistechniqueusestwoneedlesthatareintroduced intothejointspace,whereitcirculatesasacompatiblesubstancethatsaline irrigationwillpromotethisspace(VASCONCELOS;BESSA-NOGUEIRA; ROCHA,2006;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal., 2007; LOBO LEANDRO, 2007 and GROSSMAN; GROSSMAN, 2011) (Figure 11). Figure 11 Technical arthrocentesis with the introduction of the needles in the joint space. Source: VASCONCELOS, B. C. E.; BESSA-NOGUEIRA, R. V.; ROCHA, N. S. Artrocentese da articulaotemporomandibular:avaliaoderesultadoserevisodeliteratura.Rev. Brs. Otorrinolaringol., So Paulo, SP, v. 72, n. 4, p. 634-8, set./out., 2006. 916 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Theadvantagesofthisformoftreatmentisaminimallyinvasive, inexpensive,andhaslowmorbidityandcanbeperformedonanoutpatient basiswithorwithoutsedation(DOLWICK,1997;GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). Counterpart can cause complications such as infection, perforation oftheearcanal,fluidextravasationintothetissues,andbruiseswhennot appliedproperly(FROST;KENDELL,1999;GERHARDTDEOLIVEIRA; MARZOLA; BATISTA et al., 2007 and LOBO LEANDRO, 2007). ARTHROSCOPY Itisaminimallyinvasivetechniqueinvolvingcannulas,trocaters and arthroscope connected to small resolution cameras that project images on a monitor maximized (DOLWICK, 2007 and GROSSMAN; GROSSMAN, 2011) (Figure 12). Figure 12 Technique of arthroscopy. Source: DOLWICK, F. M. Temporomandibular joint surgery for internal derangement. Dent Clin. North Am., Philadelphia, v. 51, n. 1, p. 195-208, jan., 2007. Its use can be applied for diagnosis of hypermobility, hypomobility, pops,cracklesandpre-auricularpain,andtemporomandibularjoint,wherethe mainsourceofpainanddysfunctionisarticular.Also,fortheinvestigationof tumorinvasionandsystemicarthritisinvolvingtheTMJ(MARTINS,1993and ISRAEL, 1999). Ithasapplicabilityinsurgicalcasesofinternalderangementand arthropathyrefractorytoothertreatmentmodalities,suchastheanterior displacement of the articular disc without reduction in acute or chronic disease requiring lysis of adhesions, washing and handling the distal joint, hypermobility, jointdebridement,treatmenttraumaticlesionsofcapsularfibrosis,and hemarthrosis,adhesions(MARTINS,1993;ISRAEL,1999andGROSSMAN; GROSSMAN, 2011). 917 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Has the advantages of direct visualization of pathological tissues, biopsies,removalofadhesions,directinjectionofcorticosteroidsintoinflamed tissues, besides being a minimally invasive technique with less surgical trauma totheTMJandlowerpostoperativemorbidity,andhaveasmallscaras comparedtoopensurgeryoftheTMJ(DOLWICK,1997;ISRAEL,1999; GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LOBO LEANDRO, 2007 and GROSSMAN; GROSSMAN, 2011). Despitebeingaminimallyinvasivetechnique,thisprocedure dependsoncomplexandexpensivetechnology,whichrequirestrainingand skill with manual dexterity, especially in surgical procedures (DOLWICK, 1997; DOLWICK,2007;LOBOLEANDRO,2007andGROSSMAN;GROSSMAN, 2011). Possibilityofnerveinjuryofthefacialnerve,middleearor perforationoftheinternalfistulaandinjuryoflargevesselssuchasthe maxillaryarterycomplicationsareinherenttothetechniqueandthelackof knowledge (LOBO LEANDRO, 2007 and GROSSMAN; GROSSMAN, 2011). EMINECTOMY Eminectomyinvolvestheremovalofthearticulareminence throughosteotomieswiththeaidofrotaryinstrumentswithorwithoutchisels (ALMEIDA;MARZOLA;TOLEDO-FILHOetal.,1991andCARDOSO; VASCONCELOS; OLIVEIRA, 2005). Hashowindicationspatientswithsignstoodeeparticularfossa andarticulareminencewithprojectionconsideratelywide,featuringascreen mechanicallyandbypreventingpassivemovementsoftranslationafterthe onsetofrecurrentdislocationoftheTMJ(ALMEIDA;MARZOLA;TOLEDO-FILHO et al., 1991 and PASTORI; MARZOLA; TOLEDO-FILHO et al., 2008). Theobjectiveofthistechniqueistopromotetheflatteningofthe articulareminencemechanicalmovementsremovingobstaclesandallowing free to anterior and posterior condyle (ALMEIDA; MARZOLA; TOLEDO-FILHO et al., 1991 and MOUTINHO-NOBRE; CAPELARI; MARZOLA et al., 2009). Wherethereisradiologicalevidenceofvascularizationand pneumatizationofthearticulareminence,thetechniqueiscontraindicatedfor presenting risk of infection and intracranial hematoma (ALMEIDA; MARZOLA; TOLEDO-FILHOetal.,1991andMOUTINHO-NOBRE;CAPELARI; MARZOLA et al., 2009). Theprocedureisperformedundergeneralanesthesiausing approachestoaccessthejointspaceandexposureofthearticulareminence with subsequent demarcation and total removal of the entire mediolateral extent oftheeminencewiththeaidofdrillsandchisels(ALMEIDA;MARZOLA; TOLEDO-FILHOetal.,1991andPASTORI;MARZOLA;TOLEDO-FILHOet al., 2008) (Figures 13, 14 e 15). Itisasurgicalprocedurerelativeeaseofimplementationby experiencedprofessionals,havingtheadvantagesofminimalpostoperative morbidity,lowrecurrencerate,andpreservationofnormalfunctional movements(PASTORI;MARZOLA;TOLEDO-FILHOetal.,2008and MOUTINHO-NOBRE; CAPELARI; MARZOLA et al., 2009). Whenthetechniqueisnotappliedcorrectly,aportionofthe articulareminence,especiallyinitsmedialaspectisnotremoved, causingthe 918 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE frameworkofrecurrenttemporomandibulardisorder(WOLTMANN;FELIX; FREITAS, 2002). Figure 13 Demarcation of eminectomy with drills. Source:PASTORI,C.M.;MARZOLA,C.;TOLEDO-FILHO,J.L.etal.,Eminectomiacomo tratamento de deslocamento recorrente da mandbula relato de caso clnico-cirrgico. Rev. Odonto Acad Tiradentes Odontol., Bauru, SP., v. 8, n. 4, p. 201-19, abr., 2008. Figure 14 Ostectomy of eminectomy with drills. Source:PASTORI,C.M.;MARZOLA,C.;TOLEDO-FILHO,J.L.etal.,Eminectomiacomo tratamento de deslocamento recorrente da mandbula relato de caso clnico-cirrgico. Rev. Odonto Acad Tiradentes Odontol., Bauru, SP., v. 8, n. 4, p. 201-19, abr., 2008. 919 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 15 Flattening of the articular eminence with drills. Source:PASTORI,C.M.;MARZOLA,C.;TOLEDO-FILHO,J.L.etal.,Eminectomiacomo tratamento de deslocamento recorrente da mandbula relato de caso clnico-cirrgico. Rev. Odonto. Acad Tiradentes Odontol., Bauru, SP., v. 8, n. 4, p. 201-19, abr., 2008. Disadvantageshavebeenhemarthrosis,jointdegenerationand the fact that the technique is irreversible, with no therapeutic effect on the ATM, the laxity in the ligaments of the joint capsule in cases of recurrent dislocation of theTMJand,whenassociatedwithanteriordiscdisplacement(ALMEIDA; MARZOLA;TOLEDO-FILHOetal.,1991;CASCONE;UNGARI;PAPAROet al., 2008 and MOUTINHO-NOBRE; CAPELARI; MARZOLA et al., 2009). Basedonthisworkthedisadvantageofnotdamagedligaments, which is the actual cause displacement of ATM in most cases, a modification of the technique was performed, where in addition the eminectomy repositioning is performed on the disc condyle and its attachment to the lateral ligament and in thelateralcondyleresorbablescrew,withtheultimategoal,theeliminationof theobstacleeffectonboneandligamentsforcorrectionoflaxityoftheTMJ (ALMEIDA;MARZOLA;TOLEDO-FILHOetal.,1991andCASCONE; UNGARI; PAPARO et al., 2008). MINI PLATES IN ARTICULAR EMINENCE Itconsistsofanalternativesurgicalmethodforcorrectionof recurrentdislocationoftheTMJ,promotingtherestrictionofmandibular movements (MOUTINHO-NOBRE, CAPELARI; MARZOLA et al., 2009). 920 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Inordertoavoidthedevelopmentofasymmetricmandibular movements,itisrecommendedthattheprocedureisperformedbilaterally (AZENHA; SAAB; MARZOLA, 2010). Thetechniquemakesuseofmini-platesina"T"installedonthe side of the zygomatic arch, the lowest point of eminence, secured by bolts.The largest segment is wound and folded medially to the articular eminence, thereby increasingtheheight(CARDOSO;VASCONCELOS;OLIVEIRAetal.,2006; MOUTINHO-NOBRE,CAPELARI;MARZOLAetal.,2009andAZENHA; SAAB; MARZOLA, 2010) (Figures 16 e 17). Figure 16 Mini titanium plate and screws. Source: MOUTINHO-NOBRE, R.; CAPELARI, M. M.; MARZOLA, C. et al., Tratamento cirrgico limitador e facilitador de luxao recidivante da ATM Revista da literatura e relato de casos.Rev.OdontoAcad.TiradentesOdontol.,Bauru,SP.,v.9,n.1,p.1-36,jan., 2009. Theadvantagestobeareversiblemethod,lessaggressive, workingasamechanicalbarriertocontrolofmandiblemovements,however, maypresentdisadvantagesasthefractureoftheminicardwhenimproperly installed. Needjustareoperationtoremovethematerialanddecreasein maximummouthopening,andnotactontheligamentsthatcanbefound damaged (CARDOSO; VASCONCELOS; OLIVEIRA et al., 2006; MOUTINHO-NOBRE,CAPELARI;MARZOLAetal.,2009;PORTO;VASCONCELOS, 2010 and AZENHA; SAAB; MARZOLA, 2010). 921 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 17 Mini plate installed in the lateral portion of the zygomatic arch. Source: MOUTINHO-NOBRE, R.; CAPELARI, M. M.; MARZOLA, C. et al., Tratamento cirrgico limitador e facilitador de luxao recidivante da ATM Revista da literatura e relato de casos.Rev.OdontoAcad.TiradentesOdontol.,Bauru,SP.,v.9,n.1,p.1-36,jan., 2009. USE OF MINI ANCHORS Themini-anchorswereoriginallydevelopedforuseinorthopedic procedures,suchastherepairofligaments,tendonsandmusclesof reintegration (MEHRA; WOLFORD, 2001). The main function of this anchor is to attach the soft tissue on the bony structures, restoring the function (VALERO; MORALES; ALVAREZ et al., 2011). Afewyearsago,theseendosseousimplantshavebeenusedin ATM to surgical repair of recurrent mandibular dislocation with displacement of the articular disc in relation to the condyle (WOLFORD; PITTA; MEHRA, 2001). Thesedevicespromotethelimitationandcontrolofthe translationsmovimentsversingmandiblecondylarandpreventingthe displacement by remains discopexia articular stabilization of the disc in position (WOLFORD;DALLAS,1997;WOLFORD;PITTA;MEHRA,2001and SEMBRONIO; ROBIONY; POLITI, 2006). Inadditiontoanchoringthedisc,thetreatmentwithminianchors discopexiaseekstoenhancetheactionoftheligamentsthatareunstable, reduce or eliminate pain and increases the amplitude of mandibular movements (FALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). The surgical technique is performed from the exposure of the joint spaces.Thechoiceofsurgicalapproachisamatterofdebate,butthepre-922 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE auricularaccesshasbeenusedmorefrequentlywithhighsuccessrates (MEHRA;WOLFORD,2001;WOLFORD;PITTA;MEHRA,2001;ELLISIII; ZIDE,2006;FREITASBORGES;TOLEDO-FILHO;TOLEDO,2009and FALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). Thepre-auricularaccesspatternismadefromthepreparationof the surgical site with the demarcation of the posterior incision.Can be made on anaturalskinwrinklealongtheentirelengthoftheearthroughtheskinand subcutaneous tissue (Figure 18). Bluntdissectionintheanteriordirectionandthesideofthe cartilage of the ear canal to the level of the superficial layer of temporalis fascia is performed (Figure 19). Anincisionismadethroughthesuperficiallayeroftemporalis fascia, starting at the root of the zygomatic arch in front of the tragus toward the anterosuperior (Figure 20). Figure 18 Incision through the skin and subcutaneous tissue. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. 923 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 19 Dissection at the level of the superficial layer of temporalis fascia. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. Figure 20 Oblique incision through the superficial layer of temporalis fascia. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. 924 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Aperiostealelevatorisinsertedintotheincisionobliqueheld moving back and forth to promote tissue dissection (Figure 21). Afterdissectionofthetissueinthedepthoftheperiosteal detacher running an incision vertical in front of the ear canal (Figure 22). These joint capsule on the surface are retracted, and with the aid of scissors blunt dilatation is performed to enter the capsule, exposing the joint space (ELLIS III; ZIDE, 2006) (Figure 23). After exposure of the joint spaces, the technique calls for the use oftwominianchorswithosseointegrationpotential.Oneoftheanchoris secured to the back of the head portion of the condyle. Thepositionofthediskandmechanicalcondyle-diskare evaluatedaswellasthepresenceofanadhesionwhichmaybe present(WOLFORD;DALLAS,1997;WOLFORD;PITTA;MEHRA,2001; SEMBRONIO;ROBIONY;POLITI,2006andFALCHET;LOUREIRO; GAVRANICH JNIOR et al., 2011). Is necessary proper release of the ligaments, lateral and medial to allowpassivereplacementdisconthecondyle(MEHRA;WOLFORD,2001 and SEMBRONIO; ROBIONY; POLITI, 2006) (Figure 24). Figure 21 Elevator periosteal inserted underneath the superficial layer of temporalis fascia. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. 925 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 22 Vertical incision. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. Figure 23 Divulsion of the joint capsule with subsequent exposure of the joint space. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. 926 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 24 Liberation and repositioning of the disc in the same position. Source:SEMBRONIO,S.;ROBIONY,M.;POLITI.M.Disc-repositioningsurgeryofthe temporomandibularjointusingbioresorbablescrews.Int.J.oralMaxillofac.Surg,, Copenhagen, v. 35, n. 12, p.1149-52, set., 2006. Thediskisproperlymobilizedandasutureisperformedonthe medial surface and lateral repositioning it and setting it in a satisfactory position inrelationtothecondyle(WOLFORD;DALLAS,1997;WOLFORD;PITTA; MEHRA,2001;SEMBRONIO;ROBIONY;POLITI,2006andFALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011) (Figure 25). Figure25Installingminianchorintheposteriorportionofthecondylarheadandfixationof the articular disc. Source:WOLFORD,L.M.;PITTA,M.C.;MEHRA,P.Mitekanchorsfortreatmentofchronic mandibulardislocation.OralSurg.OralMed.OralPathol.OralRadiol.Endod.,St. Louis, v. 92, n. 5, p. 495-8, nov., 2001. 927 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE The second device is placed in the posterior root of the zygomatic archandfixedtothecondyleensuringthereforecontrolthetranslationofthe condyleandavoidingtheirmovement(WOLFORD;PITTA;MEHRA,2001) (Figure 26). Figure 26 Installing mini anchor in the posterior root of the zygomatic arch and fixation of the condyle by sutures. Source:WOLFORD,L.M.;PITTA,M.C.;MEHRA,P.Mitekanchorsfortreatmentofchronic mandibulardislocation.OralSurg.OralMed.OralPathol.OralRadiol.Endod.,St. Louis, v. 92, n. 5, p. 495-8, nov., 2001. Joint function is tested after the procedure to check the stability of thedisconthecondyle,avoidinganyinterferenceofscrewwithother anatomical structures during mandibular movement (SEMBRONIO; ROBIONY; POLITI, 2006). Therepositioningofthediscfacilitatesthemovementofthe condylebeforeblockedbydisplaced disk,andpromoteimproved nutrition and lubrication of articular cartilage and stabilization of the ATM (MILORO; GHALI; LARSEN et al., 2008). Thedrillingfortheinstallationofthedevicesmustbeperformed slowlyandundercopiousirrigationtominimizebonedamage,andpromoting osseointegration (MEHRA; WOLFORD, 2001). Bony delineation of the joint structures should not be made unless there is a need for removal of mechanical interference.The manipulation of the ATM should be performed so that there is no damage to the fibrocartilage of the articular fossa, condyle and articular disc to prevent the formation of adhesions and postoperative degenerative changes (MEHRA; WOLFORD, 2001). Suturingthejointcapsule,deeptissue,subcutaneoustissueand skinareroutinelydone(WOLFORD;PITTA;MEHRA,2001;ELLISIII;ZIDE, 2006;SEMBRONIO;ROBIONY;POLITI,2006andFALCHET;LOUREIRO; GAVRANICH JNIOR et al., 2011) (Figure 27 e 28). 928 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 27 Suture of the deep tissues. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. Figure 28 Skin suture. Source: ELLIS III, E.; ZIDE, M. Acessos cirrgicos ao Esqueleto Facial. 2 ed., So Paulo: Ed. Santos, 252p., 2006. 929 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Intheimmediatepostoperativeperiod,jointmobilitybeginswith isometricexercisesandadietrestrictedtoliquidstoavoidapplicationof excessiveloadsnottocauseperimplantmobility,improvingrangeofmotion (FIELDSJR.;WOLFORD,2001andFALCHET;LOUREIRO;GAVRANICH JNIORetal.,2011).Continuationofconservativetreatmentinthe postoperativeperiodmayimproveandensureasuccessfuloutcome (DOLWICK, 2007). The mostsignificantcomplicationthatcan beassociatedwiththe techniqueisfacialnerveinjury,mostcommonlyaffectingitstemporalbranch. Decreaseinsmallmouthopeningandocclusalchangesmayappearafter surgery can be circumvented with conservative treatments. Youcanusephysicaltherapy,occlusaladjustmentsanduseof occlusalsplints(TEDESCHI-MARZOLA,2005;DOLWICK,2007and VALERO; MORALES; ALVAREZ et al., 2011). Thistechniqueofusingminianchorsintheboneandcreation artificialligamentstorepositionthearticulardiskandtreatmentofrecurrent dislocationoftheTMJisquiteattractive.Donotdependonthestructural integrityofsofttissuestomaintainstabilityinthepost-surgery,oftenwith alterationsandwithexcellentresultsintermsofimprovedqualityoflifeand function of the patient (MEHRA; WOLFORD, 2001 and VALERO; MORALES; ALVAREZ et al., 2011). In counterpart depends on other factors like the angle, depth and location oftheanchor placement,suturetensionandposition,plusthedegree ofbonehealingaroundtheanchor(FIELDSJR.;WOLFORD,2001).Its contraindication is the clinical condition of TMJ dysfunction that not considered that no source joint and pain cases with diffuse, so that surgical intervention is not successful (DOLWICK, 2007). Studiesremaintobe conductedandpublishedintheliteratureto compare the results (VALERO; MORALES; ALVAREZ et al., 2011). CASE SURGICAL Patientmale,melanoderma,43,attendedtheOutpatient DepartmentofSurgeryandMaxillofacialTraumatologyBaseHospitalof theHospitalAssociationofBauru,SP,Brazil,withcomplainingofbilateral pre-auricular pain associated with the framework of recurrent dislocation of the TMJ,andanteriordisplacementofthearticulardisc.Thereweresubsequent episodesofdifficultyinspontaneousclosureofthemouthandmouthopening limitation,respectively,andintermittentlywithindeterminateevolution,butthat for years (Figure 29). Onphysicalexaminationtherehadahipperexcursionament condylar bilateral TMJ dislocation or displacement of the previous disc, with and sometimeswithoutreduction,requiringmanipulationandreductionof dislocation.Hehadpainonpalpationspecificallyintheregionofthe temporomandibular joints, and spontaneous pain and mastication (Figure 30). Suggestiveofexcessivetranslationofthecondylesofthe mandiblebeyondthepreviouslimitanatomy,thearticulareminenceswere observed and suggested as anterior displacement of the articular disc (Figures 31 e 32). 930 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 29 The frontal aspect of the patient. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 30 On physical examination with bilateral condylar hipper excursionament. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 931 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Treatmentforchronicrecurrentmandibulardislocationand/or anterior displacement of the articular disc is mainly surgical, can be achieved by correct repositioning and fixation of the articular disc on the condyle, and this to a fixed structure of the skull. Theclinicalandimagingconfirmedthecraniomandibular dysfunction diagnosis withdislocationof the TMJandanteriordisplacement of the articular disk. Theproposedtreatment,therefore,wasthesurgicaldiscopexia usingtwominianchors(Figure33).Theplanningfollowedtheinstallation sequence:1.Aminianchorwasplacedintheposteriorportionofthecondyle with subsequent repositioning of the articular disc in position by sutures.2. The secondminianchorwasinstalledonthearticulartubercle,attachedtothe condyle,andensuringthecontroloftranslationpreventingcondylar displacement. Figure 31 Panoramic radiography. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 32 Planigraphy TMJ Right and Left with open and closed mouth. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 932 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 33 Schematic figure showing the position of the mini anchor in the posterior portion of thecondyleandarticulardiscsutureinsecuringitsposition,andtheminianchor installed in articular tubercle with subsequent tie fastening it to the condylar device. Source:ModifiedfromVALERO,C.A.R.;MORALES,C.A.M;ALVAREZ,J.A.J. TemporomandibularjointmeniscopexywithMitekminianchors.J.oralMaxillofac. Surg,, Philadelphia, v. 69, n. 11, p. 2739-45, nov., 2011. Theprocedurewasperformedinahospitalundergeneral anesthesiawithnasotrachealintubation.Thesurgicalapproachofchoicefor temporomandibular joint approach was the pre-auricular access. Theincisionswerepreviouslymarkedinitiallytotheright(Figure 34),withsubsequentpre-auricularincisionbladenumber15,usinganatural foldoftheskinovertheentirelengthoftheearthroughtheskinand subcutaneous tissues (Figure35).Realized divulsiontozygomaticarchtothe level of the surface layer of temporal fascia (Figure 36). Obliqueincisionmadethroughthesuperficiallayeroftemporalis fascia, starting at the root of the zygomatic arch in front of the tragus toward the anterosuperior(Figure37).Thecuttingedgeoftheelevatorperiosteal detacher is inserted into the fascial incision, the superficial layer of deep fascia of the temporal and slid back and forth to dissection of tissue. After that, vertical incisionwasmadeinfrontoftheearcanaltothedepthoftheelevator periostealfollowedbydivulsiontohelptotheexposureofthesuperiorjoint space (Figure 38). 933 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 34 Demarcation the skin incision. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 35 Initial incision made in the natural fold of skin.Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 36 Divulsion and exposure of the surface layer of temporal fascia. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 934 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure37Incisioninthesuperficiallayeroftemporalisfasciaattherootofthezygomatic arch. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 38 Exposure of the superior joint space. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 935 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Thereleaseofligamenttissueandarticulardiskhandlingwere performedinapassivewaywiththeaidofasurgicalforcepsandablunt atraumatic (Figures 39 and 40). Verifieddiskintegrityandmobility,minianchorsAncorplan*plus wereselected.Composedoftitaniumalloyanchor,applicatorandnon-absorbablepolyestersuturewithtwoneedlesandcoupledtothescrewhead (Figures 41 and 42). Puttingaminianchorself-perforatorandself-tappingonthe posteriorportionofthecondylarhead(Figures43and44).Puttingamini anchorself-perforatorandself-tappingontheposteriorportionofthecondylar head.Realized manipulation of the articular disc and the transfixion sutures in theposterioredgeofthediskthatwillensuretherepositioningofthecondyle (Figures 45 and 46). Insertionofthesecondminianchorinthearticulartubercle (Figure47).Thesuturesofthecondyleandthearticulartubercleisthentied and fixed(Figures48and49). Mandiblewas movedindifferent directions to check the free movement of the disc and condyle. Figure 39 Release of ligament tissue Source: Images obtained from the collection of service BMF Surgery and Traumatology. ____________________________________ * Engineering Engimplan Implant 936 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 40 Manipulation of the articular disc Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 41 Mini anchors. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 937 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 42 Closer the mini anchor. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 43 Installation mini anchor in the posterior portion of the condylar head. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 938 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 44 Mini Anchor fixed with suture attached with two needle Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 45 Attaching the wires in the posterior edge of the disk. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 939 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 46 Repositioning of the articular disc on the condyle. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 47 Mini Anchor positioned in the posterior root of the zygomatic arch. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 940 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 48 Suture and fixation of the articular disc to the condylar head. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 49 Final suture restoring the function of the temporomandibular ligament. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 941 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Suture of the joint capsule, deep tissue, subcutaneous tissue and skinweremadeintheusualwaywithintradermalsuturewith4-0absorbable sutures and 6-0 nylon (Figures 50 and 51). Figure 50 Appearance of the suture end of the approach taken in the right TMJ. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 51 Aspecto da sutura final da abordagem realizada na ATM esquerda. Source: Images obtained from the collection of service BMF Surgery and Traumatology. In the postoperative period of 15 days, patients with diet liquid and pasty,withgoodaspectofsurgicalapproacheswithnocomplicationsofthe technique (Figures 52 and 53). Figure 52 Appearance of the surgical approach in the right TMJ. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 53 Appearance of the surgical approach in the left TMJ Source: Images obtained from the collection of service BMF Surgery and Traumatology. 942 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Satisfactorymouthopeningof36.25mm,acquiredalongwith physicaltherapyforearlymobilizationwiththeaimofpreventionofankylosis andmuscleatrophy(Figure.54),andpreservationoffacialmovementswith mild neuropraxia the temporal branch of the left side of the patient (Figures 55, 56, 57 and 58). Postoperativeimagingexaminationsshowingthefixationofthe mini anchors in a position (Figures 59, 60 and 61). Figure 54 Satisfactory mouth opening. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 943 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 55 Temporal branch of the facial nerve with mild neuropraxia to the right. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 56 Preservation of facial movements (zygomatic branch of facial nerve). Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 57 Preservation of facial movements (buccal branch and marginal mandibular branch of facial nerve). Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 58 Preservation of facial movements (buccal branch and marginal mandibular branch of facial nerve). Source: Images obtained from the collection of service BMF Surgery and Traumatology. 944 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE Figure 59 Panoramic radiographic. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 60 Panoramic radiograph of the right TMJ approaching. Source: Images obtained from the collection of service BMF Surgery and Traumatology. Figure 61 Ortopantomographic radiography approaching the left TMJ. Source: Images obtained from the collection of service BMF Surgery and Traumatology. 945 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE DISCUSSION Whenapatientwithinternalderangementofthe temporomandibularjointhaspainintheTMJregionofmoderatetosevere dysfunctionwithsignificantworseningofthepictureduringthemandibular movements,notrespondingtoconservativetreatment,surgeryshouldbe performedtoarticulate,especiallyincasesofdislocationrecurrentATM associated with a serious displacement of the articular disc (LEANDRO LOBO; NUNES,2000;WOLFORD;PITTA;MEHRA,2001;DIMITROULIS,2005; TEDESCHIMARZOLA,2005;GAIO;HEITZ;GERHARDTDEOLIVEIRAet al.,2006;DOLWICK,2007;GERHARDTDEOLIVEIRA;MARZOLA; BATISTAetal.,2007;LEANDROLOBO,2007andFALCHET;LOUREIRO; GAVRANICHJNIORetal.,2011).Agreeswiththecasedescribedwho presentedrecurrentdislocationoftheTMJwithanteriordisplacementofthe articulardiscthatcauseddifficultyinepisodesofspontaneousclosureofthe mouthandlimitationofmouthopening,respectively,andintermittently,in additiontospontaneouspainwhilechewing,wheretreatmentsurgerywas proposed. Arthrocentesis is one of the methods described in the literature for thetreatmentframeanteriordiscdisplacementwithorwithoutreduction, limitationofmouthopeningandpainofarticularorigin,howeverthemost successfulresultisobtainedwhentheacutephase(MARTINS,1993; DOLWICK1997,FROST,KENDELL,1999;ISRAEL,1999;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROWOLF,2007; GROSSMAN,GROSSMAN,2011andHONDA,YASUKAWA,FUJIWARAet al., 2011). Arthroscopyhasthesameindicationsofarthrocentesis,butalso surgical applicability in cases of hypermobility and having many advantages, but requires complex and expensive technology, and training and skill with manual dexterity (DOLWICK 1997, ISRAEL, 1999; DOLWICK, 2007; GERHARDT DE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007and GROSSMAN, GROSSMAN, 2011). Thetechniqueofeminectomyisanalternativetreatmentfor recurrentdislocationoftheframeworkforATM,howeverhasnotherapeutic effectonthelaxityofthejointcapsuleincasesofanteriordiscdisplacement andrecurrentdislocationoftheTMJ(ALMEIDA;MARZOLA;TOLEDO-FIET AL.,1991;GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007; LEANDROLOBO,2007;CASCONE;UNGARI;PAPAROetal.,2008; PASTORI;MARZOLA;TOLEDO-FILHOetal.,2008andMOUTINHO-NOBLE; CAPELARI; MARZOLA et al., 2009). Another method used for correction of recurrent dislocation of the TMJ is the use of mini plates in the articular eminence promoting the restriction ofmovementsduringtranslationalmovements,however,asthetechniqueof eminectomy,doesnotactonthedamagedligaments(CARDOSO, VASCONCELOS;OLIVEIRAetal.,2006;GERHARDTDEOLIVEIRA; MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007;MOUTINHO-NOBRE;CAPELARI;MARZOLAetal.,2009,PORT,VASCONCELOS,2010 and AZENHA; SAAB; MARZOLA, 2010). Anothersurgicalalternativethatpromotestherestorationofthe articulardiscandtreatmentofrecurrentdislocationoftheTMJisthe 946 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE concomitant use of mini anchors in the rear portion of the head of the condyle andtheposteriorrootofthezygomaticarch.Theywilllimitandcontrolthe translationalmovementsofthemandiblepreventingdisplacementoftheATM, aswellaskeepthe diskjointstablein positionbyreinforcingthe action ofthe ligamentswhichareunstablebycreatingartificialligaments(WOLFORD; DALLAS,1997;WOLFORD;PITTA;MEHRA,2001;SEMBRONIO; ROBIONY;POLITI,2006;GERHARDTDEOLIVEIRA;MARZOLA;BATISTA etal.,2007;LEANDROLOBO,2007;MOUTINHO-NOBRE,CAPELARI; MARZOLAetal.,2009;TAVARES;TAVARES;DIAS-RIBEIROetal.,2010 and FALCHET; LOUREIRO; GAVRANICH JNIOR et al., 2011). Comparedsurgicaltechniquesabove,theuseofminianchors showedmoreadvantagesandmorecost-effectiveisthetechniqueofchoice and used in the present case, corroborating with the literature, since it reached thegoalofreplacementofthearticulardisctothecondyleandtranslational controlofmandibularmovementseliminatingthereforetheanteriordisc displacementwithoutreductionandfixingtheframeofrecurrentdislocationof the TMJ. For exposure of the joint spaces, access most frequently used with highsuccessratesisthepre-auricularaccess,inwhichthemostsignificant complicationthatcanoccurisdamagetothefacialnerve(ELLISIII,ZIDE, 2006; SEMBRONIO; ROBIONY; POLITI, 2006; DOLWICK, 2007; GERHARDT DEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007; FREITASBORGES,TOLEDO-FILHO,TOLEDO,2009andVALERO; MORALES;ALVAREZetal.,2011),corroboratingwiththecasetheychose thisaccesstoexposureofthejointspaceswithoutshowinganydamageor injury to the facial nerve, succeeding. Thistechniqueusestwominidiscopexiaanchorswith osseointegration potential, one attached to the posterior portion of the condylar head that will reposition the disc next to it in a satisfactory position (WOLFORD, DALLAS,1997;WOLFORD;PITTA;MEHRA,2001;SEMBRONIO; ROBIONY;POLITI,2006;GERHARDTDEOLIVEIRA;MARZOLA;BATISTA et al., 2007; LEANDRO LOBO, 2007 and FALCHET, LAUREL; GAVRANICH JRetal.,2011).Theotherintheposteriorrootofthezygomaticarch (WOLFORD; PITTA; MEHRA, 2001).Closing of the joint capsule, deep tissue, subcutaneous tissue and skin are routinely done (WOLFORD; PITTA; MEHRA, 2001;SEMBRONIO;ROBIONY;POLITI,2006;GERHARDTDEOLIVEIRA; MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007andFALCHET, LAUREL; GAVRANICH JR et al., 2011).In the present case two mini anchors are installed, located in a rear portion of the condylar joint and the other in the tuber, opposing the literature was performed once a variation of the technique, howeversatisfactoryresultswithandwithoutpost-surgerycomplications.The closingofthetissueswasdoneasrecommendedbytheliteratureshowing good healing aspect of surgical approaches. The articular movements starting with isometric restricted diet and the liquid to avoid applying excessive loads in order to reduce the possibility of mobilityperiimplantarbyrupturingthebone/implantinterfaceandformationof fibrous tissue, so as to remain conservative treatment after surgery to ensure a goodresult(FIELDSJR.;WOLFORD,2001;DOLWICK,2007;GERHARDT DEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007; FALCHET; LAUREL; GAVRANICH JR et al., 2011 and VALERO; MORALES; 947 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE ALVAREZetal.,2011).Intheimmediatepostoperativeperiodthepatient's case above, restricted diet were instituted liquid/pasty accompanied by physical therapyforearlymobilization,preventingpossibleankylosisandmuscular atrophy, developed with good results, corroborating with the literature. Amongthecomplicationsthatmaybeassociatedwiththeuseof minianchorsasatreatmentforcorrectionofrecurrentdislocationoftheTMJ and anterior displacement of the articular disc without reduction, have been the reductioninmouthopeningandocclusalsmallchangesthatcanbe circumvented with treatments conservatives such as physical therapy, occlusal adjustmentsanduseofocclusalsplints(DOLWICK,2007;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007and VALERO;MORALES;ALVAREZetal.,2011).Thedivergingresults postoperatively the patient presented the case that progressed with satisfactory mouth opening without pain and occlusal changes, no need to perform occlusal adjustment or use of occlusal splints. Thus,themainobjectiveofthetechniqueisaformofadaptation andtissuerepairandrestorejointmovement.Presentsfavorableresultswith respecttotreatmentforrecurrentdislocationoftheTMJwithanterior displacementofthearticulardiscwithoutspontaneousreduction(WOLFORD, DALLAS,1997;WOLFORD;PITTA;MEHRA,2001;GERHARDTDE OLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDROLOBO,2007and FALCHET,LAUREL;GAVRANICHJRetal.,2011),however,furtherstudies remaintobeconductedandpublishedintheliteraturetocomparetheresults (GERHARDTDEOLIVEIRA;MARZOLA;BATISTAetal.,2007;LEANDRO LOBO, 2007 VALERO; MORALES; ALVAREZ et al., 2011).The clinical case surgicalpresentedsuccessobtainedasthesimilarcasesreportedinthe literature. CONCLUSIONS Fromtheliteraturereviewandpresentationofclinical-surgical case, we can conclude that: 1.Theminianchorsystemprovidesafavorablemethodfor stabilizationofthearticulardiscinrelationtothecondyleandthetranslational control of mandibular movements and can be applied to the surgical correction ofchronicrecurrentmandibulardislocation,anddisplacementofthearticular disc without reduction. 2.Promotethestrengtheningofligamentsunstable,allowing repairofthearticulartissuesfromthecreationofartificialligaments,therefore has advantages over othersurgical methods reported in the literature that have no therapeutic effect on ATM and laxity of ligaments. 3. The most significant complications related to technique are the reduction of mouth opening, also minor changes occlusal can be circumvented with conservative treatments like physical therapy, occlusal adjustments, use of occlusalsplintsaswellaslesiontothefacialnerveduringthesurgical approach. 4.Asdisadvantagesisthenecessityofexposingthejointspace andmanipulatingtissuejointbecomesfairlyinvasiveandonpostoperative morbidity, besides the high cost of the mini anchors. 948 MINI ANCHORS WITH ALTERNATIVE FOR THE RECIDIVANT LUXATION OF THE TEMPOROMANDIBULAR JOINT TREATMENT AND THE DISC DISLOCATION WITHOUT REDUCTION LITERATURE REVIEW AND SURGICAL CLINIC CASE RELATE 5.Toensureasuccessfuloutcomeinthepostoperative cooperationisneededbythepatient,followingadietrestrictedtoliquidsand pastes,withthecompletionofphysicaltherapytostrengthenmusclesand reduce the possibility of peri-implant mobility. 6.AscontraindicationshavebeenframesTMJdysfunctionis verified not be of the joint, as well as those cases presenting diffuse pain, since the surgical intervention will not be successful. 7. 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