tmj arthroscopy/ dental implant courses

TMJ Arthroscopy
INDIAN DENTAL ACADEMY
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Introduction
• Sophisticated small joint arthroscopy has
revolutionised the management of certain
TMJ disorders that were treated with open
surgery in the past

Introduction
• First introduced by Ohnishi in 1975
• It took 10 years before the Americans &
Europeans took interest in the idea of
small joint arthroscopy

Indications
• During the 1990’s there was a boom in
keyhole surgery which affected almost all
surgical disciplines
• Keyhole surgery was used to treat almost
all conceivable disorders

Indications
• Unfortunately, time and experience
showed that keyhole surgery had its
limitations

Indications
• Likewise, TMJ operative arthroscopy
peaked in the early 1990’s and gradually
fell out of favour because;
– The procedure took 3-4x as long as
conventional surgery
– Few surgeons were prepared to invest time
and energy to learn a skill that was highly
technical but never proven to be superior to
conventional treatment

Indications
• Diagnostic
• Therapeutic
– Chronic closed lock ie., non reducing disc
displacement

TMJ Arthroscopy Components

Puncture Points

Inlet vs Outlet

Arthroscopy Set-up

Normal Joint

Adhesions

Inflammation

Needle Tip

Typical Case
• 23 yo female
• 4 mn history of closed lock
• Mouth opening 27mm
• Md deviation to left side

Typical Case
• Pain in left TMJ
• No response to physiotherapy
• Cannot wear splint – limited mouth
opening
• MRI – Right TMJ non-reducing disc
displacement

Typical Case

Typical Case
Left TMJ arthroscopy
followed by physiotherapy 10 days later
At 6 weeks follow-up
- mouth opening from 27mm to 40mm
- pain reduced from 7/10 to 2/10

TMJ
ARTHROSCOPY
A Review of 56 Cases
George DimitroulisGeorge Dimitroulis

TMJ ARTHROSCOPY
Aim
• To analyse the findings andTo analyse the findings and
outcomes of 56 consecutiveoutcomes of 56 consecutive
cases of chronic closed lockcases of chronic closed lock
treated with TMJ arthroscopytreated with TMJ arthroscopy

Materials & Methods
• 3 year prospective study 1996-19993 year prospective study 1996-1999
– 60 joints (4 bilateral) in 56 consecutive60 joints (4 bilateral) in 56 consecutive
patientspatients
– TMJ arthroscopic lavage & lysis under GATMJ arthroscopic lavage & lysis under GA
– private practice settingprivate practice setting

Materials & Methods
• Inclusion CriteriaInclusion Criteria
– Closed lock <32mm mouth openingClosed lock <32mm mouth opening
– Closed lock >6 weeksClosed lock >6 weeks
– Failure to respond to physiotherapy andFailure to respond to physiotherapy and
medicationmedication
– Occlusal splint could not be fitted becauseOcclusal splint could not be fitted because
impressions could not be taken with theimpressions could not be taken with the
limited mouth openinglimited mouth opening

Materials & Methods
• Clinical Parameters:Clinical Parameters:
– pain levels - visual analogue scale 1-10pain levels - visual analogue scale 1-10
– mandibular function - interincisal distancemandibular function - interincisal distance
– level of satisfaction - questionnairelevel of satisfaction - questionnaire

Results - Intra-operative
findings
• Normal joint - 6 patients (10.7%)Normal joint - 6 patients (10.7%)
• Pathological joints - 50 patients (89.3%)Pathological joints - 50 patients (89.3%)

Results - Pathological joints
76% - fibrillation76% - fibrillation
54% - synovitis & hyperaemia54% - synovitis & hyperaemia
38% - retrodiscitis38% - retrodiscitis
38% - adhesions38% - adhesions
28% - chondromalacia28% - chondromalacia
4% - synovial villous hypertrophy4% - synovial villous hypertrophy
4% - perforated disk4% - perforated disk
2% - synovial chondromatosis2% - synovial chondromatosis

76% - fibrillation - ?surgical trauma

54% - synovitis & hyperaemia
38% - inflamm of retrodiscal tissues

38% - adhesions

Results - Mandibular function
• Pre-op mean MMO = 25.5mmPre-op mean MMO = 25.5mm ++ 5.4mm5.4mm
• Post -op mean MMO = 35.3mmPost -op mean MMO = 35.3mm ++ 6.1mm6.1mm
Mean improvement of MMO 6wks postMean improvement of MMO 6wks post
TMJ arthroscopy =TMJ arthroscopy = 9.8mm9.8mm + 0.7mm+ 0.7mm

Results - Pain scores (1-10)
• Pre-op mean pain score = 7.1Pre-op mean pain score = 7.1 ++ 1.91.9
• Post -op mean pain score = 2.4Post -op mean pain score = 2.4 ++ 1.01.0
Mean improvement of pain score 6wksMean improvement of pain score 6wks
postpost
TMJ arthroscopy =TMJ arthroscopy = - 4.7- 4.7 + 0.9+ 0.9

Results - Subjective
assessment (6wk)
• 9 patients (16.7%) - no change9 patients (16.7%) - no change
• 10 patients (18.5%) - mild improvement10 patients (18.5%) - mild improvement
• 21 patients (38.9%) - good improvement21 patients (38.9%) - good improvement
• 14 patients (25.9%) - excellent14 patients (25.9%) - excellent
improvementimprovement
• 2 patients - no data available2 patients - no data available

Results - failures (6wk)
• 9 out of 54 patients (16.7%) reported no9 out of 54 patients (16.7%) reported no
subjectivesubjective benefit from TMJ arthroscopy.benefit from TMJ arthroscopy.

Discussion
• Limitations of this studyLimitations of this study
– Lack of matched controlsLack of matched controls
– Influence of other treatment modalitiesInfluence of other treatment modalities
– No randomised selection processNo randomised selection process
– No blind assessmentNo blind assessment

Discussion
• Strengths of the StudyStrengths of the Study
– Prospective collection of dataProspective collection of data
– Consecutive patientsConsecutive patients
– Standard inclusion criteria ie. MMO <32mmStandard inclusion criteria ie. MMO <32mm
– Standard arthroscopic techniqueStandard arthroscopic technique
– Single operatorSingle operator

Discussion
• Short follow-up (6 weeks) becauseShort follow-up (6 weeks) because
– No structural changes to TMJ with lavageNo structural changes to TMJ with lavage
& lysis procedure& lysis procedure
– Influence of other treatment modalitiesInfluence of other treatment modalities
following arthroscopyfollowing arthroscopy
– Time is a great healerTime is a great healer (Sato et al 1997)(Sato et al 1997)

Discussion
• Murakami et al (1995) compared theMurakami et al (1995) compared the
short-term outcomes of 3 techniquesshort-term outcomes of 3 techniques
for management of closed lock andfor management of closed lock and
found;found;
– Conservative - 56% success rateConservative - 56% success rate
– Arthocentesis - 70% success rateArthocentesis - 70% success rate
– Arthroscopy - 91% success rateArthroscopy - 91% success rate
– (Present study - 84% success rate)(Present study - 84% success rate)

Discussion
• Israel (1999) reviewed the outcomes ofIsrael (1999) reviewed the outcomes of
11 studies of TMJ arthroscopy11 studies of TMJ arthroscopy
outcomes published btw 1987 andoutcomes published btw 1987 and
1996.1996.
• The results are strikingly similar toThe results are strikingly similar to
present study -present study - see next slidesee next slide

Comparative Studies
• Israel (1999)Israel (1999)
– 6,071 joints6,071 joints
– 3,955 patients3,955 patients
– 84% mean success84% mean success
raterate
– 10.4mm increased10.4mm increased
MMOMMO
– 4.6 units decreased4.6 units decreased
pain levelspain levels
• Present StudyPresent Study
– 60 joints60 joints
– 56 patients56 patients
– 84% success84% success
– 9.8mm increased9.8mm increased
MMOMMO
– 4.7 units decreased4.7 units decreased
pain levelspain levels

Adhesions
• Rosenberg & Goss (1999) - 124 jointsRosenberg & Goss (1999) - 124 joints
with internal derangement and foundwith internal derangement and found
adhesions in 38%.adhesions in 38%.
• Present study - adhesions also foundPresent study - adhesions also found
in 38% of joints.in 38% of joints.
• Adhesions play only a minor role inAdhesions play only a minor role in
chronic closed lock. Other factors mustchronic closed lock. Other factors must
be involved.be involved.

Osteoathrosis (OA) vs.
Internal Derangement (ID)
• Holmund et al (1994) looked at theHolmund et al (1994) looked at the
management of osteoarthosis with TMJmanagement of osteoarthosis with TMJ
arthroscopy which yielded a 50%arthroscopy which yielded a 50%
successsuccess
• Present study treated mainly internalPresent study treated mainly internal
derangement with an 84% success rate.derangement with an 84% success rate.
• Therefore arthroscopic lavage & lysisTherefore arthroscopic lavage & lysis
more effective for ID than OA.more effective for ID than OA.

Study Findings
• TMJ arthroscopic lavage & lysis is aTMJ arthroscopic lavage & lysis is a
useful and effective treatment foruseful and effective treatment for
TMJ chronic closed lock.TMJ chronic closed lock.

Discussion
• The superiority of operative arthroscopy
over simple lavage and lysis has never
been proven
• Severe joint disease is best treated by
open surgery

Conclusion
• TMJ arthroscopy is an essential part of a
Surgeon’s tool box
• Very useful for early stage TMJ internal
derangement which results in locking and
pain

tmj arthroscopy/ dental implant courses

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