Approaches to temporomandibular joint Approaches to tmj

1. APPROACHES TO THE
TEMPOROMANDIBULAR
JOINT

2. IMPORTANT STRUCTURES
Auriculotemporal nerve
• Inevitable damage – preauricular
approach.
• Runs from deep to superficial
layers as it reaches posterior
auricular region.
• Incision – close to EAM.
• Frey syndrome.

3. Superficial temporal artery
• Deep to parotid.
• Posterior to neck of condyle and crosses
zygomatic process
• Divides –
• Temporal branch
• Parietal branch
• Runs in superficial fascia

4. Maxillary artery
• Beneath – condylar neck.
• Immediate posteromedial relation.
• Endangered in condylotomy and resection of
bony ankylosis.

5. Facial nerve
•Emerges – stylomastoid
foramen
•Passes inferolaterally into
parotid.
•Length visible of main trunk
1.3cm.
•Divides – (before entering
gland)
• tempoacial
• cervicofascial

6. • Most posterior branch of temporal rami crosses zygomatic arch – 0.8cm
from EAM.
• Runs from parotidomassetric fascia, superficial to temporal fascia then
enters superficial fascia.

7. Mandibular and cervical branch
• Important structure during
submandibular and retromandibular
incision.
• Mandibular branch
• Depressor anguli oris and muscle of lower
lip.
• “Dingman” - 1.8cm behind and below
gonion.
• Cervical branch
• Platysma muscle.
• “Ziarah” – 2cm posterior to ramus
• Both run deep to cervical fascia
and lie superficia to deep fascia.

8. Layers of the Temporomandibular Region
• temporoparietal fascia – cont with superficial musculoaponeurotic
layer (SMAS). Superficial temporal vessels, temporal br of facial nerve
• subgaleal fascia- used as cleavage plane in standered preauricular
approach
• temporalis fascia

9. Approaches
•Many approaches have been proposed.
•Can be grouped as follows
• Pre-auricular
• Submandibular
• Intra-oral
• Post auricular
• Endaural
• Hoarizontal incision along the lower border of the malar arch
• Rhytidectomi incision
• Through soft tissue lacerations or scars.

10. •There is no single universal approach.
•Ideal approach characteristics.
• Be based on sound anatomical principles. Have clear
anatomical landmarks.
• Be designed to give protection to both the facial and the
auriculo-temporal nerves, and to the external auditory canal.
• Provide a relatively bloodless field.
• Provide excellent visibility of the lesional site without flap
tension.
• Be rapidly and confidently executed.
• Be uncomplicated in its repair.
• Give a good cosmetic result with minimal functional
sequelae.

11. Preauricular
Dingman’s
Blair’s
Thoma’s
Popowich’s modification of Al – kayat & Bramley’s

12. • 1979 extensive study by Alkayat and
Bramley – the first modified preauricular
incision, this was a break through.
Surgical approach
• Question mark skin incision just within
hairline.
• Vertical component as close as possible to
tragus.

13. •After reflecting superfacial fascia,
temporal fascia is visualize
•Oblique incision – 45° upwards and
forwards to zygomatic arch (2cm
above the malar arch)
•Periosteum along with superficial layer
of temporal fascia reflected.
•Dissect between cartilagenous
external auditory canal and glenoid
lobe of parotid (a-vascular region).
•Joint capsule is visualized

14. TECHNIQUE
• Step 1. Preparation of the Surgical Site
• Step 2. Marking the Incision
• Step 3. Infiltration of Vasoconstrictor
• Step 4. Skin Incision
• Step 5. Dissection to the TMJ Capsule

21. Indications
•When maximum exposure is required.
•When lateral and anterior exposure is desired.
Advantage:
•There is minimal bleeding and less sensory loss.
• Spares the main branches of vessels and nerves.
•Fascial planes are easily identified.
•There is excellent visibility.
•The potential complications of muscle herniation and
fibrosis are avoided.
• The muscle is never exposed.

22. Disadvantages:
•Scarring present.
•Threat of damage to facial nerve branches.
•Sensory loss over post-auricular skin.
•Frey syndrome.
•Damage to superficial temporal artery.

23. Endaural approach
•Introduced by Shanbaugh –
middle ear surgeries.
•Lemperts – use for TMJ.
•Different from Dingman that
it involved external auditory
meatus to a greater depth.
•Davidson modification –
superior preauricular
component.

24. Surgical approach
• I-part
• Anterior endaural incision in superior
meatal wall (depth-bony cartilagenous
junction).
• Then outward incision for 3-5mm at
conchal cartilage.
• II-part
• Extends from superior extent endaural
incision directly upwards to a point
about halfway between meatus and
upper edge of the auricle.
• III-part
• Continuous superiorly in the inter
cartilagenous cleft and becomes the
facial portion.
• After skin incision a similar
dissection as in preauricular
approach.

25. Indications:
•When lateral and posterior exposure is required.
•To avoid scarring.
Advantages:
•Excellent lateral and posterior exposure.
•Scar exposure is less.
Disadvantage:
•Limited anterior visibility.
•Demands greater skills.
•Tragal cartilage degeneration.

26. Post-auricular approach
• Introduced by Bockenheimer (1920)
• Modified by Axhausen.
Surgical technique
• Follow the line of auricle 3-4mm
posterior to it, carried down till
mastoid fascia (1st anatomical
landmark – continuous with
temporalis fascia).
• Blunt dissection about 1.5cm anterior
to auditory canal.
• Superior and posterior surface of the
external auricular canal are freed.
• Exposure of cartilagenous layer – not
necessary.

27. • Dissection of the auditory –
• Pinna…. dissected at the junction of skin and ear
canal (more towards skin).
• 2nd landmark – temporalis fascia.
• Stump of the ear canal sutured
• The posterior edge of parotid gland dissected out.
• Exposure of temporalis fascia …… lateral aspect of
articular eminence, root of zygomatic arch.
• 3rd landmark - Zygomatic arch
• Follow Alkayat and Bramley incision.
• 4th landmark – joint capsule
• Anterior pedicle pinna and tunneled skin over
temporalis along with facial layers taken
anteriorly to expose joint capsule.

28. Indications:
•When lateral and posterior exposure is required.
•Normal scar formation in the patient's history.
•Healthy ear apparatus and absence of aural sepsis.
•Normal width of the external auditory canal.
•Absence of infection or inflammation of the joint
structures.
•General health of the patient does not restrict
length of operating period.

29. Advantages:
• Excellent accessibility
especially posterior and lateral.
• Reduction in facial nerve
damage.
• No excessive bleeding.
Disadvantages:
• Limited anterior accessibility.
• Perforation of cartilaginous
external auditory meatus.
• External auditory canal
stenosis.
• Infections.

30. Risdon’s approach (Submandibular)
•Incision about finger
breadth below angle of
mandible parallel to
lower border.
•Lies between cervical
branches of facial nerve,
lower boundary of bony
EAM at least 3cm
inferior.

31. •Dissection through skin fat,
platysma and outer layer deep
cervical fascia (facial nerve lies
here).
•Anteriorly facial vessels may be
ligated.
•Identify the angle and body of the
mandible.
•The masseter and periosteum are
dissected out, parotid capsule
turned upwards.

32. Indications
• Usually for subcondylar procedure
• Severe bony ankylosis
• Direct condylar fracture fixation
• Costochondral grafting
Advantages:
• Less chances of facial nerve damage
Disadvantages:
• Inadequate accessibility
• Increased reflection and traction of tissue
• Temporary parasthesia may be present

33. Retromandibular approach
•Developed by E.C. Hinds and W.J.
Girotin (1967)
•Slight upward tilt of head
•The space between SCM and
ascending ramus identified.
•Incision parallel and posterior to
ascending ramus at distant 2cm,
starting 2.5cm vertically below
gonion and extending upwards
along the anterior border of the
SCM upto 3.5cm

34. • Dissection is made through skin, fat,
platysma and snipp off the investing
fascia.
• Structures encountered
• Posterior part of the parotid gland with
fascia, ascending ramus, deep part of
angular tract, retromandibular vessels
etc.

35. Indications
•For condylar neck fractures
•Condylotomy
•Vertical ramus osteotomies
Advantages:
•Less chances of damage to facial nerve
Disadvantages:
•Reduced accessibility
•Parasthesia of facial nerve
•Damage to retromandibular vessels

36. Intra-oral approach
• Vertical incision in the retromolar region along the ascending
ramus.
• Expose the entire medial surface of the ramus protecting the
lingual nerve and inferior dental bundle with a retractor.
• The condylar notch is visualize.
• Winstanely’s used a long, vertical incision from the tip of the
coronoid process to the depth of the buccal sulcus.
• Sear….. advocates lateral and medial exposure for
condylectomy.
• Elevation of temporal attachment might be necessary.
• If drains are required additional stab incision in the
submandibular skin.

37. Indications
•Oblique subcondylar osteotomy
•Open condylotomy (asymmetry)
Advantages
•No risk to facial and auricular temporal nerves
•No scar
Disadvantages
•Limited accessibility
•Risk of damage to lingual nerve, Inferior alveolar
bundle and maxillary artery.

38. Bicoronal flap
• Incision following hair line about 4cm
behind it.
• Depth – till subgleal loose tissue
• Inferior extent – continue as preauricular
• Blunt dissection to reflect the flap till
2cm above the infraorbital rim and
superior temporal line.
• Pericranium is incise about 3-4cm
superior to orbital rim, not to extend on
superior temporal line.
• Incision of Alkayat and Bramley
continued

39. Indication
• Bilateral exposure
• Extensive exposure required
Advantages
• Good exposure
• Easy to get the facial phase
• Reduced risk of damage to facial nerve branches
• Hidden scar
Disadvantages
• Bleeding in initial phase
• Extensive dissection required
• Not esthetic in completely bald patients

40. Rhitidectomy approach
• A variant of retromandibular approach.
• Incision – 1.5-2cm superior to level of Z arch in the
posterior aspect of the ear.
• Inferiorly and blends with the preauricular incision
anteriorly.
• Depth – skin and subcutaneous tissue
• Platysma is dissected with blunt scissor
• Expose retromandibular tissue and parotid suctions.
• Retract then to visualize pterygomesseter sling
• Incise it at the posterior border of the mandible near
the angle and reflect the flap along the ramus

41. Indications
•Esthetic is a concerned and extensive exposure is
required.
Advantages
•Less conspicuous facial carve
•Good exposure
Disadvantage
•Added time required

42. References
• Surgical approaches to facial skeleton- Edward Ellis
• Al-Kayat A, Bramley P; A modified pre-auricular approach to the
temporomandibular joint and malar arch, Br J Oral Maxillofac Surg
17:91,1979.
• The surgical anatomy of the cervical distribution of the facial nerve –
Haithem A. Ziarah et al; BJOMS (1981), 19, 171-179.
• The surgical anatomy of the mandibular distribution of the facial
nerve – Haithem A. Ziarah et al; BJOMS (1981), 19, 159-170.

43. Thank you