ppt

1. ARTHROCENTESIS
Arthrocentesis of the temporomandibular joint was first
described by D. W. Nitzan in 1991 as the simplest form
of surgical therapy with the aim of washing out
inflammatory mediators, releasing the articular disc, and
disrupting adhesions between the surface of the disc and
the joint fossa by hydraulic pressure of the lavage
solution.
TMJ arthrocentesis procedure bridged the gap between
surgical and nonsurgical treatment. It is often considered
to be the highly effective method to restore normal
maximal mouth opening and functioning.

2. RATIONALE
• There are different types of inflammatory and anti-
inflammatory cytokines, the balance of which affects
the development of degenerative and inflammatory
changes.
• Further, synovial cells and mononuclear cells
infiltrating the edge of the blood vessels also produce
IL-6 in both synovial tissue and synovial fluid. High
levels of IL-6 in the synovial fluid of the TMJ are
associated with extensive acute synovitis.

3. • In addition to this, the current clinical evidence also suggested that
the TMJ pain or dysfunction may be attributed to alterations in joint
pressure (negative intra-articular pressure) and biochemical
constituents of the synovial fluid (failure of lubrication) which may
lead to clicking and derangement of the TMJ.
• Arthrocentesis reduces the pain by allowing the elimination of
inflammatory cells from the joint space and increases the mandibular
mobility by removing intra-articular adhesions, eliminating the
negative pressure within the joint, thus recovering disc and fossa
space which reduces the mechanical obstruction caused by anterior
disc displacement.

4. INDICATIONS
• Anterior disc displacement with and
without reduction
• Disc adhesions
• Early adhesiveness next to the fossa
• Synovitis/ capsulitis
• Mouth opening limitation
• Palliation for acute degenerative
rheumatoid arthritis
• Painful joint noises occurring during
opening /or closing
• Hemarthrosis due to recent trauma

5. CONTRAINDICATION
• Psychiatric pathology
• Fibrous and osseous ankylosis
• Regional infectious disease and tumors of
the joint
• Multiple operated joints

6. PROCEDURE
• Preprocedural considerations TMJ arthrocentesis is a minimally invasive
procedure and can be comfortably performed under local anesthesia or
intravenous conscious sedation or general anesthesia, depending on patient
comfort and surgeon preference.
• Before performing the procedure, the following points should be kept in
mind:
• The surgical field is properly draped and cleaned with povidone iodine or
similar substance, particularly in preauricular region and ear
• External auditory canal is protected from accumulation of blood and fluid
using a cotton pledget
• The auriculotemporal nerve block is given, and the areas of joint penetration
should be infiltrated.

7. 2 NEEDLE TECHNIQUE
• The classical technique to perform TMJ
arthrocentesis utilizes double access to the joint
cavity. This technique uses two needles, one for
injecting and the other for aspirating the solution.
The first, more posterior
point will be marked at a
distance of 10 mm from the
tragus and 2 mm inferior to
canthotragal line. This point
corresponds to the posterior
extent of the glenoid fossa.

8. • The second point will be marked at 20 mm anterior to
tragus and 10 mm inferior to canthotragal line, which
corresponds to the height of articular eminence.

9. SINGLE NEEDLE TECHNIQUE
• The single-needle approach for the lavage of TMJ was
based on the rationale that pumping saline injection into
the superior joint compartment with the patient in an
open mouth position provides enough pressure to
release joint adherences and to allow fluid outflow when
the patient closes his/her mouth.
• The injection-ejection process must be performed for up
to 10 repetitions for a total amount of about 40 ml.

10. • INDICATIONS:
in the case of hypomobile joints with strong
adherences or joints with degenerative changes that
make the insertion of the second needle difficult

11. • Since the total circulating volume of the irrigating
solution is very low, this technique is hardly able to
eliminate algogenic substances present in the synovial
fluid of the upper TMJ compartment, responsible for
pain and bone and fibrocartilaginous changes.
• Even on exerting pressure on the syringe plunger on
the fluid, only a part will return through the needle,
regardless of patients closing their mouth. Part of the
fluid may leak from the upper compartment toward
the face, producing local edema which may generate
intra- and post-operative pain
LIMITATIONS

12. MODIFICATIONS
• Double needles in a single
cannula
• Shepherd’s single cannula
• Arthrocentesis technique with
automatic irrigation under high
pressure
• Concentric needles unit

13. POST ARTHROCENTESIS CONSIDERATIONS
• At the end of lavage, it was proposed that steroids or sodium
hyaluronate injection should be administered into the joint
space to alleviate intracapsular inflammation.
• There are many glucocorticoid preparations, but
methylprednisolone and triamcinolone (40 mg/1 ml)
preparations are long acting and may be preferable.

14. • soft diet for a few days
• Exercises of range of movement are started
immediately and continued for several days.
• Analgesics should be prescribed as necessary for
pain(Brennan and Ilankovan) suggested intra-
articular injection of morphine (10 mg in 1 ml) as a
long-acting analgesic in patients with continuing pain
in the TMJ. )

15. COMPLICATIONS
• Injury to the facial nerve
• Fifth nerve deficit
• Otic injury
• Edema due to leakage of the lavage fluid (Ringer’s
solution) into the extra-articular space
• Needle breakage (0.1%) within the joint
• Acute joint inflammation
• Allergic
• Preauricular hematoma
• Extradural hematoma
• Intracranial perforation

16. THERAPEUTIC TMJ ARTHROSCOPY
• TMJ arthroscopy is a technique for direct visual
inspection of internal joint structures, including biopsy
and other surgical procedures performed under visual
control with the help of an arthroscope.
• Arthroscopy of the TMJ has been established as a
reliable and predictable, noninvasive technique for the
treatment of internal derangement (ID) of the TMJ,
mainly for Wilkes stages II, III, and IV

17. Therapeutic Arthroscopy: Multiple punctures, with
capability for advanced arthroscopic surgical procedures.
The American Association of Oral and
Maxillofacial Surgeons (AAOMS) established five
main indications for TMJ arthroscopy:
(1) internal derangement of the TMJ, mainly
Wilkes stages 2–4
(2) degenerative joint disease,
(3) synovitis,
(4) painful hypermobility or recurrent luxation of
the disc, and
(5) hypomobility caused by intra-articular
adherences

18. Contraindications :
1.Bony and advanced fibrous ankylosis
2. Ankylosing osteoarthritis
3. Malignant tumors
4. Advanced resorption of the glenoid fossa
5. Increased risk for hemorrhage: May cause hemearthrosis.
6. Overlying skin infection: Puncturing through an infected skin
can cause septic joint postoperatively
7. Risk of tumor dissemination

19. ARMAMENTARIUM

21. 1.Arthroscopic Sheath: An arthroscopic sheath is used to
advance the arthroscope into the joint space.
2. Trocar: A trocar is used for puncturing the lateral capsule
in an arthroscopic sheath.
3. Cannulas: Cannulas are used to pass hand instruments
into the joint and for irrigation and outflow.
The devices inserted in the cannula, including the scope,
should have a diameter at least 0.1 mm smaller than the
inner diameter of the cannula. Markings on the cannulas
allows the surgeon to monitor depth of penetration.
COMPONENTS:

22. OTHER SURGICAL COMPONENTS:
Shaver Systems: Arthroscopic shavers are tools
that provide aggressive tissue resection and rapid
bone debridement during arthroscopic surgery.
• Minishavers smooths the surface of disc and
fibrocartilage.
Laser :
• The holmium:YAG laser has been shown to be
effective for the TMJ arthroscopy in reduction of
synovial and vascular hyperplasias and debridement
of fibrous tissues and therefore can be used for the
release of the anterior capsule and reduction of
chondromalacia.

23. General Principles :
In any arthroscopic surgical procedure involving small
joints, it is important to adhere to some basic technical
points:
1.The joint should remain fully distended, allowing for
easier trocar puncture and minimizing the risk of
iatrogenic intracapsular damage.
2. The skin should be punctured with a sharp trocar.

24. 3. All intra-articular procedures should be done with care to
prevent articular surface damage.
4. Attention should be given to preserve as much healthy
synovium as possible in order to enhance its physiologic
effects on the joint in any arthroscopic surgical procedure.
5. . The joint space should be kept expanded during
instrumentation by a slow infusion irrigation system.

25. PATIENT AND SURGEON POSITIONING
• The patient should lie in supine position with head
tilted laterally.
• The joint to be operated should lie parallel to the
floor or the operating table.
• The face of the patient should be directed away and
below the elbow level of the operating surgeon

26. • When operating on the right temporomandibular joint
region the surgeon should stand towards the right side
of the patient.
• Left hand of the surgeon should be the working hand,
i.e. the surgeon should hold and manipulate the scope
with the left hand.
• While operating on the left side, the scope be should
held and manipulated with the right hand standing on
the left of the patient.
SURGEON POSITION

27. Technique for TMJ Arthroscopy :
• General anesthesia-nasotracheal
• TMJ is approached through 2 trocars.
• The arthroscope is introduced through 1 port, which
also acts as the irrigation port.
• The second one is for drainage and instrument
passage. TMJ is inspected and palpated, and the
position of condylar head is determined by passive
movement of the joint.

28. For distension of the superior compartment and in order to avoid iatrogenic
damage to the cartilaginous surfaces during introduction of the trocar, 1%
lidocaine solution 2.0 mL is inserted. The needle is aimed in a medial and slightly
anteriosuperior direction until contact with the glenoid fossa is achieved

29. JOINT PUNCTURE
Through the small skin incision at the injection site,
the lateral capsule is punctured with a sharp trocar in
an arthroscopic sheath inserted in the same direction
as the previous injection needle.
The instrument is never to be passed straight through
the capsule without locating the bone.

30. The cannula and trocar are advanced to the inferolateral aspect of the
zygoma, then inferiorly stepped off the osseous ledge. The sharp trocar is
exchanged for a blunt obturator, and the arthroscopic sheath is advanced
further into the upper joint space. Correct placement can be checked by
infusing saline fluid level in the cannula that will move with the
movement of jaw. Then the arthroscope is introduced with attached
camera

32. Arthroscopically, a clinician can evaluate and describe
pathologies such as perforation, adhesion (fibrous
connective tissue bands between disk and fossa), foreign
bodies, hyperemia, corrugations (foldings), depression,
fibrillations, and folds.

33. ARTHROSCOPIC APPROACHES
There are various approaches
described for TMJ arthroscopy:
1.Superior posterolateral approach
2.Inferior posterolateral approach
3.Superior anterolateral approach
4. Inferior anterolateral approach
5. Endaural approach

36. Postoperative Medications :
• Routine NSAIDs are given for the
postoperative month and muscle relaxants for
the first week.
• Oral cephalosporin following the
intraoperative IV bolus of 1 g cephalosporin
antibiotics are routinely given for the first
week as well.
• Cortisporin otic suspension eardrops are
prescribed for the first 7 to 10 days with 2
drops in the ear canal of the affected side.

37. ARTHROSCOPIC PROCEDURES
• Lavage and lysis
• Injection of intra articular substances into the
inflamed tissues
• Arthroplasty
• Disc repositioning techniques:
1.Coblation
2. Sutures
3. Pins

38. Can be used as an adjuvant procedure when
severe chondromalacia or osteophytes are present.
In these cases the elimination of the altered
cartilage can improve joint function after surgery.
Arthroplasty can be performed using forceps,
rotary motorized instruments, oblation probes, or
laser system.
ARTHROPLASTY

39. COBLATION
• Coblation is a low-temperature technique.
• The use of coblation probes to perform anterior disc release and
posterior coagulation of the retrodiscal tissues is the preferred
surgical technique used in surgical arthroscopy of the TMJ.
• Coblation can also be used to resect adherences or to treat altered
cartilage surfaces in the joint.
• advantages are a high degree of precision, causing little or no
thermal damage to surrounding tissue, leaving smooth anatomic
surfaces, and achieving hemostasis of smaller blood vessels .

40. SUTURES AND PINS
• Although posterior repositioning of the anteriorly
displaced disc can be accomplished with the
oblation techniques already described,
stabilization of the disc in the long term is not
possible when this technique is used.
• Posterior fixation of the disc with the use of
sutures or pins could be used to stabilize the disc.

41. Stuck/Fixed Disc, “Anchored Disc Phenomenon” Anchored disc
phenomenon—ADP—is one of the possible etiologies of TMJ
closed lock .
• ADP is characterized by a sudden, severe, limited mouth
opening associated with pain on forced mouth opening. MRI
studies with the presence of a disc fixed to the glenoid fossa
facilitate a final diagnosis. Arthroscopic findings include
adherences and synovitis (hypervascularity, hyperemia, and
redundancy of the posterior ligament) both in the anterior and
posterior compartments of the superior joint space .
• Arthroscopy which permits direct visualization of pathological
tissues and allows removal of adhesions with injection of anti-
inflammatory drugs or coagulation into inflamed synovial tissue

42. Recurrent Mandibular Dislocation :
• Arthroscopy can be used to treat recurrent
mandibular dislocation.
• Different surgical techniques have been used to
create scarification and contracture in the retrodiscal
synovial tissue and the oblique protuberance.
• Coblation lasers have been reported with good
clinical results

43. Complications:
Intra-operative:
• Intra-articular damage
• Instrument breakage
• Joint irrigation, fluid extravasation
• Vascular complication(extra articular bleeding)
• Neurological complication( cranial nerve 5 and7)
Post operative: Infection, malocclusion

44. SURGICAL MANAGEMENT
Surgery of the temporomandibular joint apparatus is rarely the first line
of treatment for articular disc disorders or internal derangements.
However, persistent symptoms following nonsurgical treatment
modalities, as well as failed prior less invasive joint procedures (e.g.,
arthrocentesis, arthroscopy), may warrant open-joint surgery.

45. SURGICAL MANAGEMENT OF TMJ DISORDERS

52. CLASSIFICATION OF APPROACHES
Any approach to the TMJ must ensure the following
objectives; (a) complete visualization of structures, (b) permit
easy access to all anatomic structures to perform the required
surgical technique, (c) facilitate adequate instrumentation and
most importantly (d) eliminate the risk of facial nerve injury.

53. Preauricular :
• The preauricular is by far the most preferred and commonly
followed surgical approach to the TMJ world over.
• The advantages of the preauricular approach include (1) ease of
technique, (2) optimal exposure, (3) flexibility to incorporate
minor modifcations and (4) minimal complications.
• The original description of the approach was given by Risdon
(1934) but the technique gained popularity with the work of
Rowe and Killey in 1968 and further by Rowe again in 1972 .

54. The various preauricular incisions and their
modifications commonly mentioned in literature
include the following :
• Preauricular incision—standard
• Preauricular with temporal extension
• Preauricular—Alkayat Bramley modification
• Endaural
• Lazy “S” modification of the preauricular
approach

55. PRE AURICULAR
INCISION
Make the incision in a preauricular skin
crease from the level of the helix above the
tragus to the level of the lobule

57. Dissection of the joint capsule
Insert the periosteal elevator beneath the temporalis
fascia's superficial layer and strip the periosteum off
the lateral zygomatic arch.
Dissection will be carried inferiorly to expose the
capsule of the TMJ.
Coronal view:
The facial nerve's frontal branch is protected
within the superficial layer of the deep temporalis
fascia.

58. BLAIR’S INVERTED HOCKEY STICK L THOMA

59. ALKAYAT BRAMLEY

60. ENDAURAL
• Rongetti described a modification of
Lempert’s endaural approach to the
mastoid process for surgical improvement
of otosclerosis, for approaching the TMJ.
The endaural incisions employed today
either incorporate the anterior wall of the
external auditory canal, or the tragus

61. ENDAURAL INCISION
Endaural incision is divided
into three parts:
1. superoanterior to the
pinna,
2. inferior , just anterior to
the lobe in the most
convenient crease and
3. inside the tragus

62. RHYTIDECTOMY
• endaural incision is extended in a curvilinear fashion
around the mastoid tip
• wide surgical exposure
• direct access

63. POST AURICULAR INCISION
• Described by Alexander and
James
• The incision in the postauricular
approach begins near the
superior aspect of the external
pinna and is extended to the tip
of the mastoid process. The
superior portion may be
extended obliquely into the
hairline for additional exposure

66. SUBMANDIBULAR INCISION
• Risdon proposed the classical sub-mandibular approach .
• The Hayes Martin modifcation of the sub-mandibular approach for
protection of the marginal mandibular nerve is the most commonly
used surgical technique in current practice.

69. RETROMANDIBULAR INCISION
The retromandibular approaches expose the entire ramus from behind the
posterior border. Therefore, they are helpful for procedures involving the area
on or near the condylar process or the ramus itself.
There are two varieties of retromandibular approaches used to access the
posterior mandible. They differ in the placement of the incision and the
anatomic dissection to the mandible.
•The transparotid approach has the advantage of the close proximity of the
skin incision to the area of interest.
•The retroparotid approach has the advantage of not dissecting through the
parotid gland.

70. TRANSPAROTID
A vertical incision through the skin and subcutaneous
tissue is made, extending from just below the ear lobe
towards the mandibular angle. It should be made parallel
to the posterior border of the mandible.
Dissection
The subcutaneous tissue is undermined, exposing the
superficial musculoaponeurotic system (SMAS).
A vertical incision is made through the SMAS into the parotid
gland.

71. Blunt dissection of the parotid
gland
Subperiosteal dissection of the mandibular ramus

73. RETROMANDIBULAR APPROACH
Principles
A frequently used alternative to the retromandibular transparotid
approach described above is one in which the parotid gland is
lifted rather than dissected through
Skin incision
An oblique incision through the skin and
subcutaneous tissue is made, extending from the
mastoid process to a point just below the angle of
the mandible

74. Dissection down to parotid gland: The subcutaneous
tissue is undermined, exposing the superficial
musculoaponeurotic system (SMAS).
An oblique incision is made through the SMAS. The
posterior aspect of the parotid gland is identified, and
dissection continues behind the gland.
Incision through the
pterygomasseteric sling

76. CAPSULAR INCISIONS
1. Horizontal Incision Over the Lateral Rim of the Glenoid Fossa

77. 2. Horizontal Incision Below the Lateral
Rim of the Glenoid Fossa
• The superior joint space is punctured at
the level of discocapsular sulcus.
• A dissection is then carried inferiorly
removing the attachment of the capsule
to the disc and exposing the inferior
joint space.

78. 3. Horizontal Incisions Above and Below
the Disk :
The horizontal approach above and below
the disk leaves some of the capsule and
ligament attached to the disk or remodeled
retrodiskal tissue.

79. 4. L SHAPED INCISION
• The anterior vertical incision
should not be placed farther
anteriorly than the tubercle to
avoid injury to the facial
nerve.
• The posterior vertical incision
carries the risk of severing the
retrodiskal tissue.
• The capsule and ligament are
then reflected either
anteroinferiorly or
posteroinferiorly

81. SURGICAL MANAGEMENT OF INTERNAL DERANGEMENT

82. ARTHROTOMY
Preauricular approach to joint is common although endaural
and postauricular incision has been described in the
literature.
• Preauricular region is prepared with appropriate
antiseptic cleaning agents and draped with provisions to
manipulate the mandible (urology drape).
• The ear canal should also be prepared, and if the mouth is
to be accessed at any stage, then a preoperative
chlorhexidine mouth rinse should be employed.
• Incision is marked with or without temporal extension
(Al-Kayat/Bramley ).
• Local anaesthetic infiltration.

84. Following exposure of joint capsule,
wilkes spreader is fixed by driving k
wires into the zygoma posterior to
articular tubercle and into neck of
condyle
Tension is placed on the capsule by
expanding the spreader and superior
joint space is entered using needle
cautery

86. • Blunt tipped tenotomy scissors are used to dissect through
the lateral disc attachment to expose the inferior joint
space.
• The spreader is opened continuously as this procedure
progresses.
• On completion of this phase the glenoid fossa, disk and
condyle are visible.
• If the plan is for discectomy, a T-shaped incision is made,
using a vertical incision from the middle of the initial
horizontal incision down to the lateral cortex of the
condylar neck. This provides excellent surgical access .
• Arthrotomy procedure is standard for all disc repositioning
and diskectomy techniques.

87. DISC REPOSITIONING PROCEDURES
GOAL:
• It is to relocate the disk so that its posterior band
can be returned to the normal condyle-disk fossa
relationship.
• Essentially, the repositioning places the posterior
band over the superior or superoanterior surface
of the condyle.

88. Disk repositioning without diskoplasty is indicated in the
following instances:
• There is minimal disk displacement
• The disk is of near-normal length
• The disk structure is near normal
The rationale behind repositioning is founded on the belief that
the disease process is reversible or can be halted by normalizing
the position of the disk

89. 1. Plication in which the remodeled posterior attachment is
folded on itself and the lateral tissues are approximated

90. 2. Full thickness excision in which a wedge-shaped
portion of the posterior attachment is removed and the
lateroposterior tissues are approximated
Disk repositioning achieved through a full-thickness excision of the posterior
attachment. Retention of disk position is through sutures placed on posterior and
lateral margins. A, A clamp has been placed over the posterior attachment. The
arrow represents the direction of pull of the clamp to complete the incision and
reveal the condylar surface. B, View from above demonstrating the wedgeshaped
resection (arrow indicates

91. 3. Partial thickness excision in which the superior lamina of the
retrodiskal tissue and posterior attachment are removed, without
violation of the inferior joint space, and the lateroposterior tissues are
approximated
Disk repositioning achieved through a partial-thickness excision of the superior
lamina of the retrodiskal tissue. The inferior joint space is not violated. A, Outline
of a partial-thickness excision of the superior lamina. B, Excision is closed, resulting
in posterior repositioning of the dis

92. DISCOPLASTY AND DISC REPOSITIONING
• It is an open joint procedure in which the disc is repaired or its
shape improved.
• Often used with disc repositioning technique.
• These can also be approached with arthroscopy.
• Relapse of the disc position is frequent.

94. DISC REPOSITIONING AND
ARTHROPLASTY
• Indicated in atrophic disc
• A standard arthrotomy approach can be used,
using either a “disc-sparing” or a T-shaped
capsular incision. The disc and the superior
and inferior joint spaces are carefully
visualized, and recontouring of the articular
surfaces (with or without discectomy) is
performed
• A 2 to 4 mm condylar-eminence arthroplasty
procedure can be performed with rotary or
hand instruments. Hand instruments such as
fine chisels are preferable to avoid heat
generation
• A periosteal elevator may be used to burnish
sharp edges.

95. DISC REPOSITIONING USING MITEK ANCHORS
• Anterior and anteromedial disc displacement.
• Disc stabilization in conjunction with high or low
condylectomy.
• Four years or less since onset of disc displacement.
• Salvageable disc and condyle.
• No significant intracapsular adhesions
• No other joint involved (no polyarthritis)
• No reactive arthritis.
• No connective tissue/autoimmune diseases.
Proponents of the Mitek anchor technique recommend
specific patient selection criteria be followed to maximize
surgical outcomes including:

96. a) Sagittal view of the right TMJ. The TMJ articular disc is anteriorly displaced (green arrow). Bilaminar
and synovial tissues cover the top of the condyle. This tissue is excised to eliminate excessive tissue
when the disc is repositioned. The ligament that attaches from the anterior aspect of the disc to the
anterior aspect of the articular eminence must be detached in order to mobilize the disc and
reposition it passively over the condylar head (red arrow).
b) The disc has been mobilized and repositioned passively over the condyle. A hole is drilled into the
posterior head of the condyl(e with the dedicated Mitek drill, and the Mitek anchor is inserted into
the posterior head of the condyle into the medullary bone with the wings locking it in place against
the cortical bone. The 0 Ethibond suture that was doubled and passed through the eyelet of the
anchor provides two artificial ligaments to secure the disc in position.

97. Posterior view of the anchor inserted into the condyle. The pilot hole is placed approximately 8 mm below the crown
of the condylar head and just lateral to the midsagittal plane. The first suture (artificial ligament) is passed from
beneath up through the posterior aspect of the posterior band of the disc toward the medial side. Two more throws
are completed for a total of three throws. The second suture is passed in the same manner with three throws but
positioned more laterally. The disc should be slightly overcorrected, and then the sutures are tied. Additional support
sutures can be placed, for example, at the lateral pole area if additional support is required to stabilize the disc
laterally. The 0 Ethibond suture can be passed through the lateral capsular tissue and up through the lateral aspect of
the disc and secured to provide additional lateral support

98. PARTIAL DISKECTOMY/ DISC RESHAPING
• Indicated to correct partial reducing disk displacement.

99. TOTAL DISKECTOMY
• Total diskectomy is the procedure in which the remodeled
posterior attachment and entire disk are excised.
• It is indicated in those situations for which disk repositioning
is not feasible because of disk atrophy, deformation, or
severe degeneration.

100. DISKECTOMY PROCEDURE
• The joint space is accessed using the standard arthrotomy
approach (with the T-shaped capsular incision) .

101. • Once the joint space is accessed, the disc must be separated entirely from the lateral
capsule and retrodiscal attachments, with meticulous hemostasis since the retrodiscal
tissues are highly vascular.
• Perhaps the most challenging aspect of the discectomy procedure is the release of the
anterior (lateral pterygoid muscle) and medial (medial capsular ligaments) attachments
since access is limited and the potential for significant bleeding exists in both locations
(e.g., branches of the maxillary artery).
• Using a combination of blunt and limited sharp dissection, the disc should be carefully
freed from the medial and anterior attachments to avoid leaving a portion of the disc in
situ which may lead to persistent joint symptoms postoperatively.
• Following discectomy, the disc itself should be confirmed to be “completely removed,”
and the entire joint space must be carefully inspected to ensure no disc remnants
remain.

102. • In the case of disc replacement, the disc substitute material is trimmed
to the appropriate size and shape and placed into the joint space.
• The disc substitute can potentially be sutured to the retrodiscal tissue
attachment remnants and the lateral pterygoid muscle and lateral
capsule with nonresorbable sutures.
• Without any discal remnants remaining, it is difficult to place sutures
to secure the disc replacement material on the medial aspect of the
joint space. Some authors have advocated the use of postoperative
intermaxillary fixation after replacement of the disc to allow initial
stabilization to prevent immediate displacement with condylar
function.

103. • Finally, the wounds are irrigated with saline and suctioned, and
some joint lubricant (e.g., sodium hyaluronic acid) may be
placed into the joint space, and the capsule, fascia, subcutaneous
tissues, and dermal layers are closed using resorbable sutures,
and the skin is closed using resorbable or nonresorbable sutures.
• The wound is dressed with antibiotic ointment and gauze, with a
pressure dressing. The use of a postsurgical occlusal appliance
and/or the commencement of postoperative physical therapy
should be guided by surgeon preference and individual patient
requirements.

104. DISCECTOMY WITH REPLACEMENT
• Autogenous, homologous, and alloplastic replacements for the
disk have been used following diskectomy to prevent or reduce
intra-articular adhesions, osseous remodeling, and recurrent pain.
• In addition, the interpositional material was believed to decrease
joint noises by dissipating loading forces on the osseous surfaces.
• The commonly used materials include autogenous grafts like
dermal graft, auricular cartilage graft and temporalis muscle or
fascia

105. TEMPORALIS FASCIA

106. • The flap is turned into the joint space, either
over or under the arch of the zygoma and
secured with six sutures (5-0 resorbable
sutures such as polyglyconate or
polydimethylsiloxane (PDS)): two sutures in
the medial capsular region, two sutures in the
anterior attachment, and two sutures in the
posterior attachment.
• A gravity drain or suction drain may be used
for 24–36 hours. The capsule is then repaired
and sutured to the lateral aspect of the flap,
and the wounds are closed in a layered
fashion. The use of a postsurgical occlusal
appliance and/or the commencement of
postoperative physical therapy should be
guided by surgeon preference and individual
patient requirements.

107. AURICULAR CARTILAGE GRAFT
• Posterior approach commonly
followed.
3–4 cm approach back of the
pinna
Raising the graft, the
perichondrium is preserved
on the anterior auricle

109. • Alloplastic materials: Most commonly, a silastic sheet was used
as a temporary interpositional material following discectomy to
allow for fibrous tissue encapsulation of the silastic sheet and
the formation of a fibrous “pseudodisc” that would function to
protect the articular surfaces.
• Allogeneic cartilage has been used previously in animal
studies which have shown progressive resorption of these
materials with eventual replacement with a fibrous
pseudodisc. Other studies have demonstrated some
protective effects on the articular surfaces despite
perforation, displacement, or resorption of the graft .

110. DISC PERFORATION
• Perforations rarely occur within the disk proper but
rather within the lateral third of the remodeled
posterior attachment.
• Prolonged joint loading, with anteriorly displaced
disc without reduction.
• Condylar overgrowth often occurs in the areas of the
perforations; therefore, an arthroplasty is frequently
performed in conjunction with the procedure.

111. • MANAGEMENT OF SMALL PERFORATIONS(2-3mm)
• If the disk is to be fully repositioned, the margins of the
perforation should be excised and the posterior attachment on
the posterior edge of the disk approximated to the tympanic
portion of the retrodiskal tissue.
• Anterolateral release of the diskal attachments is usually
necessary to mobilize the disk posteriorly.
• The margins of the perforation are oversewn in a straightline
fashion with a nonresorbable material. The repair procedure is
often performed in conjunction with an arthroplasty to reduce
sharp bony spurs that may be present

112. MANAGEMENT OF LARGE PERFORATIONS
• Large perforations are usually grafted after
excision of the edges. The disk is not
repositioned. In many cases this procedure is a
partial diskectomy.
• The graft material is laid over the perforation
and posterior attachment.
• The free edges of the graft are sutured to the
underlying posterior attachment and disk

115. HYPERMOBILITY
Hypermobility disorders may be subdivided into
subluxation and dislocation.
• SUBLUXATION : a self-reducing partial dislocation of
the TMJ, during which the condyle passes anterior to the
articular eminence.
• DISLOCATION: Temporomandibular joint dislocation
involves a non self-limiting displacement of the condyle,
outside of its functional position within the glenoid fossa
and posterior slope of the articular eminence

116. MANAGEMENT
ACUTE:
• The major problem is overcoming the resistance of the
severe spasm.
• Therefore , initial attention is given to reduce tension,
anxiety and muscle spasm.
• This can be achieved by:
1. Reassuring the patient
2. Tranquiliser or sedative
3. Pressure and massage to the area
4. Manipulation

117. • A simple technique – Johnson
• LA is injected into the depression in the glenoid
fossa left by the dislocated condyle.
• Spontaneous reduction, in bilateral cases with the
injection of one point can occur with a swallow in 1
to 10 minutes.

118. • Hippocrates: The manual reduction method is performed by
first pressing the mandible downward, then backward, and
finally upward.
• Lewis modified it in his way by stating that the patient should
be made to sit down and the clinician should stand in front of
him/her or at 11o’ clock position. Then, the thumb should be
pressed down on the occlusal surface of the lower molar teeth.
At the same time, the chin should be elevated with the fingers
and the entire mandible should be pushed posteriorly.
• Few authors have further modified the technique by changing
the position of the thumb from the occlusal surface of the teeth
to the anterior border of the ramus

119. YURINO’S METHOD

120. Syringe technique- hand’s free approach :
• 5- or 10-mL syringe is placed between the posterior
upper and lower molars or gums on one of the
affected sides.
• The patient is then instructed to gently bite down on
the syringe while rolling it back and forth between
the teeth until the dislocation on that side is reduced.
Typically the opposite side reduces spontaneously. If
this does not occur, then the syringe can be placed
on the opposite side and reduction performed in the
same manner.

121. • EXTRA – ORAL REDUCTION

122. •Apply a barrel bandage around the mandible and head of the
patient for 24 hours
• Post reduction imaging is recommended to ensure adequate
reduction and to exclude the presence of an avulsion fracture.
Avoid extreme opening of the jaw for three weeks.
•Support the lower jaw when yawning.
•Maintain a soft diet for one week.
AFTER CARE AND FOLLOW UP

123. SURGICAL MANAGEMENT
• Indicated in recurrent and longstanding chronic dislocation not
responsive to closed manipulation and non surgical treatment.
• 3 broad categories of procedures:-
1. To limit translation( anchoring, blocking, myotomy procedures)
2. To eliminate blocking factors in condylar path of closure
3. both

124. CAPSULORRHAPHY
• A cicatricial contracture is created
with the removal of retrodiscal
synovial tissue.
• The capsule is tightened and sutured
to the desired position. External or
open capsulorrhaphy procedure can
be performed as an open joint
surgical procedure .

125. MacFarlane (1977) has described capsular plication as a simple and
effective method for recurrent dislocation of the temporomandibular
joint.

126. • Neiden’s method:
• Reinforcement of the joint
capsule by turning down a
strip of temporalis fascia
and suturing it to the joint
capsule.

127. • LIGAMENTORRHAPHY:
• It involves the surgical
fixation (or anchoring) of the
lateral ligament of the capsule
to the periosteum of the
overlying zygomatic arch,
followed by MMF for 1 week.

128. • Plication of the condyle to the temporal bone and of the coronoid
process to the zygomatic arch have also been described.
• Multiple materials have been used for plication procedures,
including both resorbable and nonresorbable sutures and wire.
• Miniplates and surgical anchors have also been used in both the
lateral pole of the condyle and the posterior roof of the zygomatic
arch.
• Wolford and colleagues have described the threading of heavy
suture material between the eyelets of the surgical anchors, thereby
preventing condylar dislocation

129. LATERAL PTERYGOID MYOTOMY
• Rationale is to reduce or eliminate the
muscular force thought to be responsible for
pulling the mandible into dislocated position.
• It involves excision of lateral pterygoid
muscle at the condylar neck and joint
capsule.
• Disable the lateral pterygoid muscles,
allowing only rotational movements of the
condyle.
• Laskin advocated lateral pterygoid myotomy
with silicone to prevent reattachment.
CREATION OF NEW MUSCLE BALANCE

130. TEMPORALIS SCARIFICATION
• Temporalis scarifcation creates a cicatricial
restriction in dynamic muscular function, and
reduce condylar translation.
• This technique was proposed by Gould JF.
• This procedure principally involves dissecting
the tendinous fibres from the ascending ramus
and suturing them to the surrounding
periosteum and mucosa, this induces
tightening of the tendon by scaring.
• The length of the tendon or the muscle may be
surgically reduced depending on the amount of
hypermobility.

131. BLOCKING PROCEDURES
Blocking or arthroereisis procedures to interfere with
translation are designed to create obstacles for the condyle.
SOFT TISSUE PROCEDURE:
Konjetzny’s procedure: fixation
of disc in an anterior position.
• It is anchored vertically in
front of the condyle by
suturing it to the lateral
pterygoid muscle inferiorly
and to capsule laterally.

132. BONY
• Foged and other authors – rebuilding of eminence to
create a block to condylar translation.
Mayer advocated a graft (taken over from
zygoma) placed over the eminence to
increase the size and height.

133. Lindermann performed an osteotomy on the eminence
and turned it down in front of the condylar head to
prevent its forward movement.

135. Mechanical Obstruction with Mini-plate Placement

136. ELIMINATING BLOCKING FACTORS IN
CONDYLAR PATH
• A torn or displaced disc caught behind the
condyle or a prominent articular eminence
may act as an obstacle .
• Two procedures which accomplish this are:
diskectomy, eminectomy

137. The eminectomy procedure was first introduced
by Myrhaug in 1951 as a treatment for chronic
and habitual dislocation of the condyle.
EMINECTOMY

138. COMBINE PROCEDURE TO ELIMINATE THE
BLOCKING AND LIMIT TRANSLATION
• Lateral pterygoid myotomy with diskectomy
• Condylotomy
• Condylectomy

139. LATERAL PTERYGOID MYOTOMY WITH DISKECTOMY
• First described by Boman
• Anterior gliding movement is restricted by lateral
pterygoid myotomy
• Diskectomy eliminates obstruction by disk
• Recurrent dislocation

140. CONDYLOTOMY
• Condylotomy is an osteotomy procedure which releases the condyle
and allows it to displace anteriorly and sag inferiorly.( extraoral and
intra-oral approach)
• Condylotomy is the only extra-articular surgical procedure for the
treatment of painful temporomandibular (TM) joint.
• The procedure reduces the strength of the lateral pterygoid muscle by
shortening it while allowing to remain functional.
• Indicated in: condylar hypermobility and subluxation(anteromedial
subluxation of disc)

141. • Early proponents created an osteotomy that was short and
subcondylar, to mimic a subcondylar fracture.
• To decrease the incidence of inadvertent medial displacement
or anterior displacement of the condylar head with respect to
the eminence, the osteotomy orientation was changed to be
more vertical, thus the change in name from “subcondylar
osteotomy” to “intraoral vertical ramus osteotomy,” also
known as the modified condylotomy.

142. • GOALS :
1. Is to increase joint space by caudal movement of the condylar segment.
2. to reduce joint pain,
3. to improve function, and
4. to possibly decrease risk of TMD progression from simple anteriorly displaced
disc with reduction to anteriorly displaced disc without reduction to more
serious degenerative joint
• The major advantage of modified condylotomy compared with other surgical
procedures for the TM joint is that it is extra-articular. Because there is no intra-
articular damage or scarring resulting from the operation, there is virtually no
chance that the joint will be worse after the operation, even when a condylotomy
fails to relieve pain adequately.

143. INTRA-ORAL CONDYLOTOMY/ INTRAORAL VERTICAL
RAMUS OSTEOTOMY
Anesthesia preparations:
• General, nasotracheal intubation, stabilize tube.
• Neuromuscular blockade for ease of jaw opening.
• IV prophylactic antibiotic and steroids.
Place throat pack and prep mouth with chlorhexidine rinse.
• Apply MMF system of choice, with the understanding that
maintenance of fixation followed by guiding elastics will be
needed for many weeks.
• Bite block to the contralateral side.
• Infiltration of local anesthesia with epinephrine to the
buccal vestibule.

144. • The oblique ridge of the mandible is identified by
palpation.
• The incision starts over this ridge, at the level of the
occlusal plane , and extends forward approximately 3 to
4cm.
• The anterior part of the incision should be 2 to 3mm from
the mucogingival junction to minimize subsequent scar
contracture and creation of a food trap.
• Carry incision through submucosa, muscle, and
periosteum, and laterally retract the flap to expose the
ramus of the mandible, taking care to develop an
atraumatic soft tissue envelope.
• Smoothly dissect all periosteum off the lateral ramus, so
that the sigmoid notch, posterior ramus, and inferior
border can be visualized

145. OSTEOTOMY
• Helpful instruments include a set of lighted
Bauer retractors to visualize the sigmoid notch
and the antegonial notch;
• the Levasseur-Merrill retractor to retract the
masseteric sling, stabilize the ramus during the
osteotomy, and allow for proper A-P
positioning of the oscillating saw blade.

147. ANTELINGULA: landmark for initial cut.
• 2nd important is the posterior border: vertical osteotomy is
made 8mm from the posterior border, mandibular nerve
damage is prevented.
• Use the oscillating saw blade in a continuous sawing manner;
the blade cuts best when one moves and rotates the blade
against the bone, using the fan-shaped blade at an angle to start
and continue the cut. Once the bony cut is well defined from
the mid-ramus to the sigmoid notch, proceed straight down to
the inferior half of the osteotomy.

148. • For best visibility, remove the Bauer from the sigmoid notch, and place the
opposite Bauer in the antegonial notch. Many surgeons aim to bring the
inferior half of the cut slightly anterior to the angle of the mandible. The
reasons for this are twofold: by curving the osteotomy anteriorly as one
approaches the inferior border of the mandible, the free (proximal) segment is
less likely to end in a sharp pointy bony tip. In addition, the proximal
segment remains attached to a portion of the medial pterygoid muscle on the
medial side. Refine the saw cut to ensure that the osteotomy is full thickness
from top to bottom.
In patients with a small mandible, there may not be enough
room for both a Levasseur-Merrill retractor and a Bauer
retractor at the sigmoid notch. In that case, a modified
curved freer or a ramusmeasuring instrument that is marked
at 7–10 mm can be used to engage the posterior mandible

150. BUTT END RELATIONSHIP
LAP JOINT

151. Finish:
• Irrigation of wound
• Tight wound closure with polyglactin suture
• Removal of the throat pack
• Application of strong maxillomandibular fixation (MMF)
using wires or elastics
• Head wrap and ice pack for swelling
Postoperative course:
• Tight MMF is needed for the first 3–4 weeks, with the longer
period advised for bilateral cases. This is followed by up to 4 weeks
of progressively lighter-guiding elastics to assist the patient with
finding his/her occlusion and to discourage chewing. Toward the
end of the guiding elastic period, the patient may briefly remove
elastics and initiate gentle range of motion exercises. Food with
slightly firmer texture may also be started.

152. • After release of fixation and removal of the arch bar devices,
physical therapy is strongly encouraged to restore normal range of
motion and jaw strength. Physical therapy may be supplemented by at-
home jaw exercises consisting of jaw opening repetitions and stretch-
and-hold sequences.

154. CONDYLECTOMY
• Low condylectomy or simply condylectomy is the procedure that is defined as the
removal of the entire condylar process.
• The procedure used to be performed to increase the joint space to alleviate pressure on
nerve endings,48 but it has largely been abandoned in the surgical repertoire for
treatment of internal derangements because of problems of reduced condylar mobility,
mandibular deviations, and open bite.
• High condylectomy is the removal of only the articular surface of the condyle. The disk
is left intact to prevent ankylosis and to promote healing. This contrasted with the
radical condylectomy in which the tendon of the lateral pterygoid muscle was released.
Only slight mandibular deviation was reported in patients after high condylectomy.

155. TOTAL JOINT REPLACEMENT
• Replacement of the temporomandibular joint (TMJ)
is a complex procedure as TMJ is among the most
complicated articulations in the body.
• End-stage TMJ disease can lead to severe disability
in mastication and speech affecting the physical,
social, psychological, and overall quality of life.

156. GOALS OF TMJ REPLACEMENT
The goals of TMJ replacement include:
• restoration of form and functions of TMJ as close as possible
to the natural joint;
• to improve quality of life;
• to maintain ramal height and prevent facial asymmetry;
• to provide pain-free maximal incisal opening (MIO);
• prevention of recurrence like in TMJA cases;
• concomitant orthognathic surgery for facial correction;
• to limit excessive treatment and cost;
• to prevent further morbidity.

157. Indications for alloplastic TMJ replacement include :
1. severe inflammatory arthritis involving the TMJ not responsive
to other treatment modalities;
2. recurrent fibrous or bony ankylosis especially in cases where
joint is anatomically mutilated;
3. failed autogenous graft and alloplastic devices; destruction of
graft tissue by pathology;
4. loss of ramus height and condylar resorption;
5. connective tissue and autoimmune disease (juvenile idiopathic
arthritis, ankylosing spondylitis, scleroderma).

158. CONTRAINDICATIONS
• the age of the patient (the use of TJR in skeletally immature
patients is still not proven as alloplastic prosthesis does not
have growth potential);
• uncontrolled systemic disease;
• active infection at the surgical site;
• allergy to the implant material.

159. STOCK VERSUS CUSTOM-MADE ALLOPLASTIC PROSTHESIS
• Custom devices are manufactured/printed from the
preoperative CT scan data of anatomy of the lateral
surface of mandible and the fossa so that it fits the lateral
surface of mandible and fossa without much preparation.
• In the case of stock, prosthesis bone fits the prosthesis.

160. Advantages of the stock prosthesis are :
Immediate availability, size flexibility, and lower cost
than a custom joint.
Disadvantages are questionable fit of the joint especially
in a longstanding disease-causing warping of the
mandible , longer intraoperative time as the bony surface
has to be prepared to fit the prosthesis, limited potential
for anteriorinferior movement of the mandible, and
surgical experience is required to manage the variability
of fit.
Imperfections in fit can cause material fatigue, and
subsequent micromotions eventually lead to prosthesis
failure.

161. • Custom-made TJR can adapt easily; no
alteration of patient’s bone is required.
• It also addresses the issue of distorted
anatomy like warping of the mandible.
• It requires less operative time, excessive
anterior-inferior movement is possible, and
the total contact surface between prosthesis
and bone allows improved osseointegration
and stability .
• Custom TJR allows controlled occlusal
correction and proper mastication without
simultaneous orthognathic surgery. The
posterior stop present in the fossa design
reduces the chances of dislocation.

162. Indications of the one-stage protocol are when the patient can
maintain occlusion in CT, when aesthetics are satisfactory, and
when fossa anatomy is easily adjusted with minor corrections
at planned surgery.
Indication of two-stage alloplastic replacement is fossa or
condyle anatomy that requires significant modifications or
resection, significant bony ankylosis, when significant
occlusal alterations are necessary, resection of large tumors of
the TMJ region with associated hard tissue defects, and
removal of failed alloplastic hardware.

166. 1. Presurgical orthodontics completed with appliances
remaining in place or application of arch bars or other
method for skeletal and dental stabilization if orthodontic
appliances not applied
2. Condylectomy (or removal of TMJ spacer if two-stage
approach), joint debridement, and recontour fossa if indicated
.
3. Coronoidectomy if the mandible is significantly advanced or
ramus lengthened vertically, to detach the temporalis muscle
or if the coronoid process is hyperplastic creating
interference with the zygoma. Otherwise, a coronoidectomy
is not indicated
Step-by-step surgical sequencing for TMJ reconstruction

167. 4. Detach the masseter muscle from the ramus. The media pterygoid
muscle is detached only if the mandible is significantly advanced or
ramus lengthened vertically
5.Recontour ramus if indicated from the stereolithic model
preparation
6. Mobilize mandible if indicated (i.e., significant anterior open bite
requiring counterclockwise rotation of the mandible)

168. 7. Contralateral mandibular ramus sagittal split osteotomy if only
a unilateral TJP and the mandible is malaligned .
8. Maxillo-mandibular fixation and placement of the surgical
splint, only if indicated. With a good dentition, a splint is usually
not necessary
9. Contralateral mandibular ramus osteotomy, application of
rigid fixation, and closure of the intraoral incision, if only a
unilateral total joint prosthesis

169. 10. Placement of total joint prosthesis(es)
11. Reattach masseter muscle(s) to angle of mandible and close
submandibular incision(s)
12. TMJ fat graft (harvested from the abdomen, buttock, or
elsewhere) and packed around the articulation area of the
prosthesis(es). Closure of incisions
13. Remove maxillo-mandibular fixation. Completion of surgery