basic for arthroscopy

1. TMJ ARTHROSCOPY
BY – DR.DHAVAL TRIVEDI
MDS PART – II

2.  The temporomandibular joint (TMJ) has a more
complicated anatomy and function than any
other human joint.
 Its position close to the dense bone of the skull
base makes it difficult to examine clinically and
radiographically.
 Improvement of diagnostic methods in this area
is therefore desirable

3.  TMJ Arthroscopy is a technique for direct visual inspection of
internal joint structures, including biopsy and other surgical
procedures performed under visual control which comprises
use of an Arthroscope.
 Arthroscopy was first described by Takagi in 1939
 Ohnishi in 1975 ,published first report on TMJ arthroscopy
 He used no. 24 watanabe 1.7mm telescope
J Oral Maxillofac Surg 47386-389.1989

4. INDICATIONS
 Internal derangement
 Osteoarthritis
 Arthritides
 Pseudotumors
 Post-traumatic complaints
 To perform biopsy

5. CONTRAINDICATIONS
 Bony ankylosis
 Advanced resorption of the glenoid fossa
 Infection in the joint area
 Malignant tumors
 Increased risk for hemorrhage
 Increased risk for infection
 Fibrous ankylosis

6. ARTHROSCOPY EQUIPMENT
 General: suction, Lactated Ringer’s IV bag for irrigation,
marking pen
 Specific
 TMJ instrument set
30-degree arthroscope
 0 , 70 ,120 degree

7.  Trocars – sharp & blunt
 Canullas
 Holomium laser
 Fluid infusion system

8. Shavers
 Light Cord
 Camera

11. PROCEDURE
 Performed under G.A or local anaesthesia ccombined
with sedation
 Auriculotemporal nerve block & infiltration in
subcutaneous tissue lateral to the joint
 Supine position to reduce the risk of inducing a
vasovagal reaction
 Upper compartment is distended with 2ml lignocaine
till resistence felt
 After 3 ml , distension should be stopped

13.  Inferolateral approach is used to gain good access to posterior
part of upper compartment of TMJ
 With this approach access to anterior recess is limited
 Best to puncture lower compartment
 Anterolateral approach provides better access to anterior recess
of upper compartment
 Endural approach give view of lateral part of upper compartment
 Lower compartment puncture ????

14.  Telescope should always be used to ensure that the
arthroscopic sheath has been correctly placed
 An outflow portal is then created about 5 mm anterior
to & slightly below the sheath
 Continuous irrigation is performed using isotonic
saline solution
 For longer procedure ringer’s solution should be used
as it protect the chondrocytes & maintain the
synthesis of proteoglycans

15.  Examination begins with identification of landmarks
the boundary between the disk & posterior disk attachment ,
the medial capsule , the inferior part of eminence & anterior
capsule
 Posterior disk attachment is the predominant location for
inflammation like increased vascularity , capillary hyperemia ,
synovial hyperplasia
 Loss of well defined boundary between posterior part of the
disk & posterior disk attachment indicates degenerative
changes usually found in joints with chronic locking &
osteoathritis

16.  During alternate opening & closing movements, any elongation of
the posterior disk attachment is revealed
 The arthroscope the should be moved more medially to visualize
the medial capsule
 After that it is directed anteromedially , when mouth is closed
slightly it will slip under eminence into anterior recess

17. SURGICAL PROCEDURES
 Lavage
 Lysis
 Lateral capsule release
 Disk repositioning
 Synovectomy
 Debridement & Abrasion
 Restriction
 Intraarticular pharmacotherapy

18. COMPLICATIONS
 Vascular injury
 Extravasation
 Scuffing
 Broken instruments
 Otologic complication
 Intracranial damage
 Nerve injury
 Infection

19. Why arthroscopy ??
 It has become an important method for the diagnosis
& treatment of TMD
 Its accuracy in diagnosing TMD is high &
simultaneous biopsy can be performed to improve
diagnostic accuracy
 Some procedures like lysis & lavage can be done
under L.A
 Shorter hospitalization & less cost effective

20. THANK YOU