Surgical approaches of TMJ /certified fixed orthodontic courses by Indian dental academy

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Surgical approaches of TMJ /certified fixed orthodontic courses by Indian dental academy

  1. 1. SURGICAL ANATOMY OF THE TEMPOROMANDIBULAR JOINT AND SURGICAL APPROACHES INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. INTRODUCTION The TMJ and its components frequently require exposure for a myriad of procedures. Internal derangements of the TMJ, arthritis, trauma, developmental disorders, and neoplasia may all affect the TMJ and/or the skeletal and the soft tissue components. www.indiandentalacademy.com
  3. 3. Several approaches to the TMJ have been proposed and used clinically. Pre auricular Modifications – Blair’s • • • • • • Thoma’s Al – kayat and Bramleys Popowich’s modification of Al – kayat and Bramleys Endaural approach Post auricular approach Submandibular (Risdon’s ) approach Post ramal ( Hind’s ) approach Hemicoronal approach Coronal or bicoronal approach www.indiandentalacademy.com
  4. 4. The selected approach should accomplish the following: Maximize exposure for the specific procedure Avoid damage to the branches of the facial nerve Avoid damage to major vessels Avoid damage to the parotid gland Maximize use of natural skin creases for cosmetic wound closure www.indiandentalacademy.com
  5. 5. PRE AURICULAR APPROACH The pre auricular incisions used today are essentially modifications of Blair curvilinear or inverted L incision. www.indiandentalacademy.com
  6. 6. FACIAL NERVE The main trunk of the facial nerve exits from the skull at the stylomastoid foramen. Approximately 1.3 cm of the nerve is visible before it divides into temporofacial and cervicofacial branches. www.indiandentalacademy.com
  7. 7. FACIAL NERVE During surgery by incising the superficial layer of the temporalis fascia and the periosteum over the arch inside the 8 mm boundary, damage to the branches of the upper trunk can be prevented. www.indiandentalacademy.com
  8. 8. FACIAL NERVE The temporal branch of the facial nerve innervates the frontalis, the corrugator, the procerus and occasionally a portion of he orbicularis oculi muscle. Post surgical palsy manifests as an inability to raise the eyebrow or wrinkle the forehead and ptosis of the brow. Damage to the zygomatic branch results in temporary or permanent paresis to the orbicularis oculi. www.indiandentalacademy.com
  9. 9. AURICULOTEMPORAL NERVE The auriculotemporal nerve supplies sensation to parts of the auricle, the external auditory meatus, the tympanic membrane, and skin in the temporal area. Damage to this nerve can be prevented during surgery by incising and dissecting in close apposition to the cartilaginous portion of the external auditory meatus www.indiandentalacademy.com
  10. 10. PRE AURICULAR APPROACH Marking the incision. Infiltration of vasoconstrictor. If LA is also used it should not be injected deeply .. nerve stimulator www.indiandentalacademy.com
  11. 11. PRE AURICULAR APPROACH Incision thru skin sc tissues including the temporoparietal fascia till the superficial layer of temporalis fascia. www.indiandentalacademy.com
  12. 12. Blunt dissection to undermine superior part of incision ( above ZA ). Flap dissected at the level of outer layer of temporalis fascia. Below the ZA blunt dissection adjacent to the EAC followed by scissor dissection. www.indiandentalacademy.com
  13. 13. www.indiandentalacademy.com
  14. 14. Incision through the superficial (outer) layer of temporalis fascia beginning from the root of the ZA just in front of the tragus anterosuperiorly toward the upper corner of the retracted flap. The fat globules contained between the layers of TF are exposed. At the root of the zygoma incision is thru superficial layer fo temporalis fascia and periosteum of the ZA. www.indiandentalacademy.com
  15. 15. Blunt dissection with periosteal elevator deep to superficial layer of temporalis fascia to dissect it from underlying areolar and adipose tissue. Cleave the attachment of the periosteum at the junction of lat. and sup. surfaces of the ZA. www.indiandentalacademy.com
  16. 16. Continue blunt dissection inferiorly, taking care not to dissect medially into the TMJ capsule. www.indiandentalacademy.com
  17. 17. As the dissection proceeds approximately 1 cm below the ZA the intervening tissue is released along the plane of the initial incision. www.indiandentalacademy.com
  18. 18. Distracting the condyle inferiorly, pointed scissors are used to enter the upper joint space anteriorly along the posterior slope of the eminence. This opening is extended anteroposteriorly by cutting along the lateral aspect of the eminence and the fossa. www.indiandentalacademy.com
  19. 19. The inferior joint space is opened by making an incision in the disk along its lateral attachment to the condyle within the lateral recess of the upper joint space. www.indiandentalacademy.com
  20. 20. MODIFICATIONS OF THE PRE AURICULAR INCISION Al Kayat and Bramley modification of the pre auricular incision. The temporal incision is carried thru the skin, superficial fascia to the level of the temporalis fascia. Facial n. brs. run in the superficial fascia, so full length of the fascia should be reflected with the skin flap. www.indiandentalacademy.com
  21. 21. Blunt dissection carried out till about 2 cms above the ZA where the temporalis fascia splits. Starting at the root of the ZA an incision is made….. Downward dissection will expose the capsule and then the dissection is carried out as usual. www.indiandentalacademy.com
  22. 22. ADVANTAGES Reduction in the incidence of facial nerve palsy. Provision of donor site for temporalis fascia. Decreased haemorrhage (disseciton thru avascular plane) Improved visibility and identification of fascial planes. Reduction in post op edema and discomfort. Potential complications of muscle herniation and fibrosis are avoided. Good cosmetic result. Reduction of total operating time. www.indiandentalacademy.com
  23. 23. MODIFICATIONS OF THE PRE AURICULAR INCISION www.indiandentalacademy.com
  24. 24. ENDAURAL APPROACH The endaural incision is simply a cosmetic modification of the pre auricular incision. It moves the skin incision from the pretragal crease posteriorly so that the incision is placed on the prominence of the tragus itself. In the superior portion the incision is deepened to the level of the temporalis fascia. Inferiorly sharp dissection is carried out for some distance along the perichondrium. www.indiandentalacademy.com
  25. 25. www.indiandentalacademy.com
  26. 26. SUBMANDIBULAR APPROACH SURGICAL ANATOMY Marginal mandibular Br. of the facial nerve Dingman and Grabb – dissection of 100 facial halves. They found marginal mandibular was upto I cm below the inferior border of the mandible in 19% cases Anterior to the point where the nerve crossed the facial artery the nerve was above the inferior border in all the cases. www.indiandentalacademy.com
  27. 27. 21 % of the cases had a single marginal mandibular branch. 67 % had 2 branches. 9 % had 3 branches 3 % had 4 branches. www.indiandentalacademy.com
  28. 28. ZARIAH and ATKINSON In 53% OF 76 facial halves the marginal mandibular branch was below the lower border of the mandible before reaching the facial vessels. In 6 % of the cases the nerve continued further upto 1.5 cm before turning upward to cross the mandible. The farthest distance from the inferior border of the mandible was 1.2 cm. In view of these findings the incision and deeper dissection should be at least 1.5 cm below the inferior border www.indiandentalacademy.com
  29. 29. Facial artery The facial artery appears on the external surface of the mandible around the anterior border of the masseter muscle. Facial vein The facial vein generally courses with the facial artery above the level of the of the inferior mandibular border but it is posterior to the artery. www.indiandentalacademy.com
  30. 30. Marking the incision The incision is 1.5 – 2 cm inferior to the mandible. Infiltration of vasoconstrictor with local anesthetic should not be deep to the platysma muscle – marginal mandibular br. www.indiandentalacademy.com
  31. 31. The initial incision is carried through the skin and sc tissue to the level of the platysma muscle. The skin is undermined with scissor dissection in all directions to facilitate closure. www.indiandentalacademy.com
  32. 32. Division of the fibers of the platysma can be done sharply or in a more controlled method www.indiandentalacademy.com
  33. 33. Dissection thru the superficial layer of deep cervical fascia Care should be taken to avoid damage to the marginal mandibular nerve. The facial vessels can be retracted or clamped, divided and ligated as required. www.indiandentalacademy.com
  34. 34. Dissection continues until the only remaining tissue on the inferior border of the mandible is periosteum (ant. to the premasseteric notch) or the pterygomasseteric sling. www.indiandentalacademy.com
  35. 35. The pterygomasseteric sling is sharply incised with a scalpel along the inferior border. This is the most avascular portion of the sling. www.indiandentalacademy.com
  36. 36. Strip the masseter. www.indiandentalacademy.com
  37. 37. POST RAMAL (HIND’S) APPROACH SURGICAL ANATOMY Facial nerve Retromandibular vein www.indiandentalacademy.com
  38. 38. Skin marking Infiltration of vasoconstrictor. The incision begins 0.5 cm below the lobe of the ear and is about 3 – 3.5 cm long. The initial skin incision is carried thru the skin, sc tissue to the level of the platysma. Skin undermining.. www.indiandentalacademy.com
  39. 39. The platysma muscle is sharply incised in the same plane as the skin incision. Then the superficial musculoaponeurotic layer and parotid capsule are incised and blunt dissection begun within the gland in anteromedial direction toward posterior border of the mandible. www.indiandentalacademy.com
  40. 40. Hemostat is inserted parallel to the anticipated direction of branches of the facial nerve. The dissection continues until the only tissue remaining on the posterior border of the mandible is the periosteum of the pterygomasseteric sling. www.indiandentalacademy.com
  41. 41. Retraction of the tissues is done. The pterygomasseteric sling is sharply incised with a scalpel. www.indiandentalacademy.com
  42. 42. Strip the masseter. Clean dissection is facilitated by stripping the muscle from top to bottom. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com
  44. 44. POST AURICULAR APPROACH The incision begins near the superior aspect of the external pinna and is extended to the tip of the mastoid process. The incision is made 3 – 5 mm parallel and posterior to the post auricular flexure. The incision is carried sharply down thru the postauricular muscle to the mastoid fascia and the temporalis fascia superiorly. www.indiandentalacademy.com
  45. 45. A combination of blunt and sharp dissection is used to isolate the cartilaginous portion of the external auditory canal. A blunt instrument is placed in the EA canal to assist in the transection of the EA canal. The incision should leave 3 – 4 mm of cartilage on the medial aspect to permit adequate approximation of the canal. www.indiandentalacademy.com
  46. 46. The incision is carried thru the outer layer of the temporalis fascia, continuing inferiorly, reflecting the parotidomasseteric fascia off the ZA and the lateral TMJ ligament. www.indiandentalacademy.com
  47. 47. HEMICORONAL AND BICORONAL INCISIONS These are more extensive, but versatile surgical approach to the upper and middle regions of the facial skeleton, including zygomatic arch and the TMJ areas. The major advantage of this approach is that most of the scar is hidden within the hairline when the incisions are extended into the preauricular region, the surgical scar is inconspicuous. The incision can be utilized for more extensive bilateral involvement. www.indiandentalacademy.com
  48. 48. REFERENCES COLOR ATLAS OF TMJ SURGERY – PETER D. QUINN FONSECA ORAL AND MAXILLOFACIAL SURGERY VOL. 4 – BAYS and QUINN THE TMJ AND RELATED OROFACIAL DISORDERS – BUSH and DOLWICK SURGICAL APPROACHES TO THE FACIAL SKELETON – EDWARD ELLIS SURGERY OF THE TMJ. SURGICAL ANATOMY AND SURGICAL INCISIONS – KREUTZIGER (ORAL SURGERY. 58; 637-646, 1984) A MODIFIED PRE AURICULAR APPROACH TO THE TMJ AND MALAR ARCH – ADIL AL KAYAT AND PAUL BRAMLEY (BJOS. www.indiandentalacademy.com
  49. 49. 1 www.indiandentalacademy.com

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