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Technical Note

TMJ Disorders

A better view of thetemporomandibular joint:a technical note

C. J. Perumal, M. M. Bouckaert, A. S. Singh: A better view of the temporomandibular  joint: a technical note. Int. J. Oral Maxillofac. Surg. 2011; 40: 207–208. # 2010International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

C. J. Perumal, M. M. Bouckaert,A. S. Singh

Department of Maxillofacial and Oral Surgery,Faculty of Oral Health Sciences, MEDUNSACampus, University of Limpopo, No. 1 Ga-Rankuwa Street, Ga-Rankuwa, Pretoria 0204,South Africa

 Abstract. The authors present a method of gaining access to the temporomandibular  joint that improves visibility and surgical access. It should reduce operating timesand improve results.

Keywords: temporomandibular joint; view.

Accepted for publication 20 September 2010Available online 25 October 2010

  New methods of gaining access to thetemporomandibular joint (TMJ) arerequired that will improve visibility and surgical access, reduce surgeon and assis-tant fatigue, reduce operating times and improve results. The authors present amethod that attempts to fulfill these criteria.

Technique

After pre-auricular exposure of the TMJ,two 1.5 mm or 1.6 mm Kirschner wires(K-wires) are selected (Fig. 1). The K-wires can be plain or threaded. Using anSS White 701 carbide bur, two holes are

made, one at the neck of the condyle (lowenough on the condylar neck to not inter-fere with the lateral capsule reinforce-ment) angled at 458 and the other,approximately 1 cm from the zygomatico-temporal prominence, also at an angle of 458 (Fig. 2). This should be accomplished 

  Int. J. Oral Maxillofac. Surg. 2011; 40: 207–208doi:10.1016/j.ijom.2010.09.016, available online at http://www.sciencedirect.com

         

  Fig. 1. (A) Mandible retractor: Leibinger 1-05860. (B) Mandibleretractor: Walter Lorenz 01-0633. Arrow indicates 1.5 mm Kirsch-ner wire.

         

 Fig. 2. Course of the facial nerve relative to the zygomatic arch and mandibular condyle (adapted from Peterson’s Principles of Oral and Maxillofacial Surgery. London: Hamilton). Arrows indicate the place-ment position of the Kirschner wires.

0901-5027/020207+ 02 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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after subperiosteal dissection under directvision. As per operator choice, TheK-wires are then tapped or threaded intothese holes, such that they convergetowards each other (Fig. 3). The K-wiresare then cut to an equal height and stretched in the direction opposite to their angles of convergence. Self-retainingretractors (Fig. 1) are inserted and torqued open as desired (Fig. 4).

Should increased retraction becomenecessary, the converging K-wires may be angled towards each other to form anX configuration and then stretched in thedirection opposite to their angles of con-

vergence. Pre-drilling and tapping of theK-wires allows for adjustments in angula-tions. Direct threading, while simple and time saving, requires initial placementaccuracy. Repeated threading may posea risk of fracture. This allows for anexcellent view of the TMJ and good accessto the articular disc (Fig. 5).

Discussion

This technique provides good access and visibility of the TMJ, which is a compli-cated two-compartment, four-surfaced   joint system. It permits better surgicalinstrumentation by facilitating distractionof the TMJ to allow better intra-articular visualization and management of intra-articular pathology. This technique offersan added benefit to the use of the Wilkesretractor.

The two potential sources of facialnerve injury are dissection anterior tothe posterior glenoid tubercle where thetemporal branches cross the arch, and 

aggressive retraction at the inferior marginof the flap where the main trunk and temporofacial division are located. Tran-sient neuropraxia of the temporal branchesof the facial nerve, inferior alveolar and less commonly, the lingual nerves mayresult from clamp placement for jointmanipulation. Auriculotemporal syn-drome (gustatory sweating, Frey’s syn-drome has been repor ted as a result of dissection of the joint)1. Better visualiza-tion of the TMJ and easier use of surgicalinstrumentation helps to minimize these

complications and improve surgicalresults.

The authors of this technique report no  postoperative complications using thistechnique.

Competing interests

 None declared.

Funding

 None.

Ethical approval

 Not required.

Reference

1. Miloro M, Ghali GE, Larsen PE,Waite PD. Surgery for internal derange-ments of the temporomandibular joint.Peterson’s Principles of Oral and Maxillo-facial Surgery. London: Hamilton 2004:989–1014.

Address:Colin Jerome Perumal

 Department of Oral and   Maxillofacial Surgery

School of Oral Health SciencesUniversity of LimpopoPO Box 1870  MEDUNSA 0204South AfricaTel.: +27 844371746 

 fax: +27 866498058.E-mail: coljer@tiscali.co.za

208 Perumal et al.

         

  Fig. 5. Articular disc held by curved arteryforceps.

         

  Fig. 3. Position of pins after placement and beforeinsertion of retractors.

         

 Fig. 4. Viewof TMJ after torquingthe mandibular retractors open. 1 indicateszygomatic arch; 2 indicates mandibular condyle,arrow indicates articular disc.