Objectives Surgical Treatment for Temporomandibular Joint Disorders

Describe indications and surgical procedures for

Arthrocentesis Arthroscopy Discectomy Condylotomy Arthroplasty for TMJ ankylosis

Objectives
Be able to describe the most common TMJ tumors and their clinical and radiographic findings Be able to describe the indications and options for total joint reconstruction

TMJ Anatomy

Evaluation and Diagnosis

1. Clinical exam 2. Imaging
A. orthopantomogram B. tomograms C. MRI D. CT E. arthrogram F. arthroscopy

Common diagnoses
TMJ arthralgia Capsulitis MFPD ADD with or without reduction Degenerative joint disease

Surgical options
Arthrocentesis Arthroscopy Arthroplasty/arthrotomy
Disc plication Diskectomy with or without interpositional graft Disc repair condylotomy Indications:

Arthrocentesis
TMJ arthralgia ADD with reduction/with pain ADD without reduction chronic or acute Previously operated joints without pain relief

Should be reserved for pts that have failed non-surgical therapy

Arthrocentesis
Contraindications
Limitation of motion without pain Bony or fibrous ankylosis Extracapsular causes of pain and dysfunction

Arthrocentesis
Procedure:
Single or dual port lavage technique Same landmarks as placing scope Use large bore needle instead of scope Lavage joint, hydraulically break adhesions, place steroid

Arthrocentesis
Advantages over arthroscopy
Less invasive, can be performed comfortably under IV sedation Disadvantage: cannot visualize joint space/disc

Arthrocentesis
Efficacy
Literature reports 70-95% success rate Prospective, randomized comparison of arthroscopy and arthrocentesis (Fridrich, et al. JOMS, 1996) showed no significant difference between overall success. (82% for arthroscopy, and 75% for arthrocentesis)

Arthroscopy
6-year multicenter retrospective study; 4,831 joints. (McCain et al. JOMS 1992) Reviewed outcomes of arthroscopy performed in six diagnostic categories.
Internal derangement with closed lock, internal derangement with painful click, osteoarthritis, hypermobility, fibrous ankylosis and arthralgia) Greater than 90% favorable outcomes in four health outcomes.

Arthroscopy
Technique
Single, dual and triple port procedures reported. Diagnostic arthroscopy Lysis and lavage Disc plication Laser procedures

Arthroscopy
1 port technique

technique
Ave entry point 10-13mm ant. To tragus 2mm inf to canthal tragal line. If two ports used; 2 nd port is 10mm anterior to posterior port. (anterior port is into ant recess of sup. Joint space) Distend joint; needle place in an anteriomedial direction feeling for articular eminence Walk needle into sup joint space Place sharp trochar then blunt, then camera. Sweep joint to break adhesion, then lavage

Adjunctive procedures
Laser or electrocautery to cauterize and scar the posterior attachment to inhibit ADD Disk suturing procedures (sutures passed posteriorly and tied in EAM
No good randomized clinical trials or studies comparing to arthroscopy alone

Complications
Vascular injury and hemorrhage Neurologic injury (MCF perf) Peripheral nerve injuries; facial nerve, trigeminal nerve (infraorbital, lingual, IAN, auriculotemporal) Infection Otologic: laceration or hematoma in EAC

Complications
Otologic: Aual-tmj fistula, perf of TM, otitis externa, otitis media Trauma to parotid gland: sialocele or fistula formation (no actual reported cases)

Arthroplasty-Open Joint Procedures

Disk plication Disk repair Diskectomy with or without placement of interpositional graft Condylotomy Tx for chronic subluxation, dislocation

Approaches for Arthroplasty

Preauricular Endaural Postauricular Preauricular or endaural with superior extension (Al-Kayat modification)

Autogenous Grafts
No studies show that placement of graft material is superior to diskectomy alone. Temporalis fascia Postauricular cartilage Dermis

Temporalis fascia

Condylotomy
Indications:
Used in past for tx of internal derangements ADD with or without reduction, or mandibular hypomobility Creates condylar sag

Tx for chronic subluxation/dislocation

1. Eminectomy 2. LeClerc procedure 3. Soft tissue procedures for restricting movement:
Capsulotomy Myotomy

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Le Clerc procedure

Complications
Hemorrhage Infection CN VII damage CN V damage Otologic complications MCF perforation and dural tear Malocclusion

Management of Ankylosis
Kaban et al. JOMS, 1990: made recommendations for a protocol of treating ankylosis
Aggressive resection of the ankylotic segment Ipsilateral coronoidectomy; occ. Contralateral Lining the joint with autogenous tissue Consider costochondral graft in severe cases (secure with rigid fixation)j Aggressive physiotherapy for at least 1 year

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TMJ Tumors
Malocclusion-open bite Tumenscence Absence of Diagnosis
Referral MRI

TMJ Tumors
Beware of Adenocarcinoma Most likely
Osteochondroma Osteoma Condylar hyperplasia

TMJ Tumors
Unlikely Diagnoses
Synovial chondromatosis Pigmented villonodular synovitis

Imaging Obtained:

CT Scan MRI Axial Sagittal Coronal

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Treatment: Incisional Biopsy

Diagnosis: Pigmented villonodular synovitis

Treatment
Coronal flap with infratemporal fossa dissection and osteotomy of the zygomatic arch Tumor extirpation
Extracranial Intracranial Synovectomy

Immediate reconstruction of glenoid fossa with cranial bone graft Post operative control

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Diagnosis and Treatment Plan

Diagnosis
Right Osteochondromal vs. hemimandibular hyperplasia

Treatment
Le Fort I osteotomy to level occlusion Right preauricular approach to proximal mandible with resection of lesion Inferior border ostectomy of mandible with IAN lateralization

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 1.5 year control MIO = 40 mm No evidence of recurrence on conventional imaging Deviation to the right upon opening

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Problems: Inability to masticate Sibilant speech distortion Hypomobility Bilateral preauricular pain with function

Relevant imaging findings: Bilateral medially displaced condylar heads Significant vertical ramus deficiency Single bone plate anterior mandible

Treatment options
Orthognathic surgery
LF I BSSRO

TMJ reconstruction
Costochondral graft(s) Alloplastic reconstruction

ORIF condyle fracture(s)

P.J. Pre-op 12-05-00

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P.J. Post-op 01-05-01

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Treatment Plan
TMJ reconstruction with costochondral graft to left mandible with 5 mm augmentation of vertical height Intermaxillary splint with 5 mm posterior open bite created on left Orthodontic control with passive eruption of permanent teeth with left maxillary aveolar development

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2 years prior to presentation

Status post multiple joint debridements Treatment performed LF I osteotomy Genioplasty

J.S. 12-09-99

J.S. 02-29-00

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J.S. Pre-op 04-19-02

J.S. Pre-op 04-19-02

Treatment Plan
Stereolithographic model Bilateral patient fitted total joint replacements temporomandibular joints Correction of malocclusion Post operative physiotherapy

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J.S. Post-op 09-05-02 J.S. Post-op 09-05-02

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Thank you

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