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CHAPTER 50 Surgery for Internal Derangements of the Temporomandibular Joint Leslie B. Heffez, DMD, MS The chapter on surgery for internal derangements of the temporomandibular joint (TMJ) written for the first edition, published in 1992, has stood the test of time. The surgical procedures described are still being performed today, which is indicative of their acceptance within the surgical com- munity and perhaps of their success. The history of TMJ surgery has paralleled the rise and subsequent all but disappearance of the western cowboy. New surgical tech- niques that neglected to pay attention to the fundamental underlying symptoms and eti- ology have been heralded as panaceas, only to rapidly fade into obscurity, leaving a trail of iatrogenia. The new TMJ surgeon must be wary of this past. However, prudence should not lead to avoidance of surgery as a treatment modality. According to Annandale, Sir Astley Cooper was the first to suspect the existence of altered condyle disk-fossa relations. 1 Later the term internal derangement was adopted to describe any pathologic entity that interfered with the smooth function of the TMJ. The term is currently used exclu- sively to describe alterations in disk-fossa relations. Historically, clinicians have recog- nized that surgery for internal derange- ments should be reserved for patients with pain or dysfunction that is severe and dis- abling and is refractory to nonsurgical management. These conditions still form the basic indications for surgery. Open surgery of the TMJ for primary disease has undergone a complete metamorphosis as a result of the research and clinical results of surgical arthroscopy. At one time only a handful of surgeons professed the viability of function with a displaced disk and argued against surgical repositioning. Today the tables are reversed, and the majority of surgeons recognize that an internal derangement does not imply an ipso facto need for surgery. Furthermore, the presence of persistent symptoms in light of an internal derangement does not imply that surgical correction is necessary or imminent. Only if the mechanical obstruction is felt to be the primary etiolo- gy behind the symptoms is surgery indicat- ed. This philosophy has resulted in a dra- matic reduction in the number of open surgical procedures performed. This reduc- tion has, in turn, resulted in dramatically fewer cases deemed to have an iatrogenic pathology; we continue to grapple with the 1980 to 1990 vestiges of such cases. The chapter begins with sections on criteria for diagnosis and goals for surgical intervention. A brief discussion of surgical anatomic considerations is followed by a description of the classic surgical approaches to the joint capsule and capsu- lar incisions. A critical review of the histo- ry, indications, rationale for performance, and techniques of primary operations of the TMJ is then presented. Numerous ref- erences are made to those authors who have fueled the development of surgery for internal derangements. In my discussions I have used the term posterior attachment to describe tissue that is an extension of the retrodiskal tissue and inserts onto the pos- terior aspect of the disk. When the adjec- tive remodeled is used to qualify an intra- articular structure, as in remodeled posterior attachment, the structure is con- sidered pathologic. Criteria for Diagnosis Internal derangements are classically divid- ed into two groups: reducing disk displace- ments and nonreducing disk displace- ments. Qualifying descriptors are sometimes included, such as the direction of displacement, degree of displacement, and presence of a perforation. Unfortu- nately, these large diagnostic rubrics fail to identify the finer stages of the disease

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Page 1: cirugia atm

C H A P T E R 5 0

Surgery for Internal Derangements of the Temporomandibular Joint

Leslie B. Heffez, DMD, MS

The chapter on surgery for internalderangements of the temporomandibularjoint (TMJ) written for the first edition,published in 1992, has stood the test of time.The surgical procedures described are stillbeing performed today, which is indicativeof their acceptance within the surgical com-munity and perhaps of their success. Thehistory of TMJ surgery has paralleled therise and subsequent all but disappearance ofthe western cowboy. New surgical tech-niques that neglected to pay attention to thefundamental underlying symptoms and eti-ology have been heralded as panaceas, onlyto rapidly fade into obscurity, leaving a trailof iatrogenia. The new TMJ surgeon mustbe wary of this past. However, prudenceshould not lead to avoidance of surgery as atreatment modality.

According to Annandale, Sir AstleyCooper was the first to suspect the existenceof altered condyle disk-fossa relations.1

Later the term internal derangement wasadopted to describe any pathologic entitythat interfered with the smooth function ofthe TMJ. The term is currently used exclu-sively to describe alterations in disk-fossarelations. Historically, clinicians have recog-nized that surgery for internal derange-ments should be reserved for patients with

pain or dysfunction that is severe and dis-abling and is refractory to nonsurgicalmanagement. These conditions still formthe basic indications for surgery. Opensurgery of the TMJ for primary disease hasundergone a complete metamorphosis as aresult of the research and clinical results ofsurgical arthroscopy. At one time only ahandful of surgeons professed the viabilityof function with a displaced disk andargued against surgical repositioning.Today the tables are reversed, and themajority of surgeons recognize that aninternal derangement does not imply anipso facto need for surgery. Furthermore,the presence of persistent symptoms inlight of an internal derangement does notimply that surgical correction is necessaryor imminent. Only if the mechanicalobstruction is felt to be the primary etiolo-gy behind the symptoms is surgery indicat-ed. This philosophy has resulted in a dra-matic reduction in the number of opensurgical procedures performed. This reduc-tion has, in turn, resulted in dramaticallyfewer cases deemed to have an iatrogenicpathology; we continue to grapple with the1980 to 1990 vestiges of such cases.

The chapter begins with sections oncriteria for diagnosis and goals for surgical

intervention. A brief discussion of surgicalanatomic considerations is followed by adescription of the classic surgicalapproaches to the joint capsule and capsu-lar incisions. A critical review of the histo-ry, indications, rationale for performance,and techniques of primary operations ofthe TMJ is then presented. Numerous ref-erences are made to those authors whohave fueled the development of surgery forinternal derangements. In my discussions Ihave used the term posterior attachment todescribe tissue that is an extension of theretrodiskal tissue and inserts onto the pos-terior aspect of the disk. When the adjec-tive remodeled is used to qualify an intra-articular structure, as in remodeled

posterior attachment, the structure is con-sidered pathologic.

Criteria for Diagnosis

Internal derangements are classically divid-ed into two groups: reducing disk displace-ments and nonreducing disk displace-ments. Qualifying descriptors aresometimes included, such as the directionof displacement, degree of displacement,and presence of a perforation. Unfortu-nately, these large diagnostic rubrics fail toidentify the finer stages of the disease

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process. Disk morphology and severity ofdisplacement are only gross indicators ofthe disease process. Although more compli-cated classifications such as the Wilkes clas-sification exist, the treatments applied tothe diagnostic categories have been diverse,rendering specific recommendations illadvised. It suffices to say that an astute clin-ician must be armed with that rare com-modity of common sense rather than arigid algorithm of treatment modalities.The research and clinical work emanatingfrom arthroscopic trials will, in the future,establish more specific diagnostic criteriafor establishing treatment protocols.

In the surgical decision-makingprocess the specific diagnosis is only onepiece of information necessary to makethe decision to perform surgery. Surgeryshould be considered when the dysfunc-tion or pain cannot be corrected to a levelof patient satisfaction by nonsurgicalmodalities. Cookbook approaches to thediagnosis and surgical management ofinternal derangements should not be used.It is important to consider that no dys-function is identical to another when thesurgeon factors into the treatment equa-tion the patient’s perception of his or herproblem, the effect on daily routine, andthe patient psyche. The diagnosis of aninternal derangement is achieved predom-inantly through clinical skills. Imaging ofthe joint usually is most useful only in thelater planning stages of surgery, ratherthan during the establishment of a work-ing diagnosis. There is the occasionalinstance in which a diagnostic dilemmaexists and magnetic resonance imaging(MRI) is required to elucidate the case.

For the sake of discussion, the condi-tion internal derangement can be identi-fied in three different clinical settings. Thefirst is the occurrence of a primarily func-tional disturbance. In this condition thechief complaint is functional. The patientsmay describe a need to perform a specialmaneuver with the mandible to achieve awide opening, or they may describe an

annoying terminal jolting associated withclosing. Joint pain is typically not chronicand appears to be related to the instabilityof the condyle-disk relations. Pain occurswith the sudden separation of joint sur-faces during disk reduction or displace-ment. However, pain may not be a feature.Most of these cases demonstrate a reduc-ing disk displacement, in which the diskrepresents a mobile mechanical obstacleand the condyle is not permanentlyrestricted in its range of motion. Reduc-tion refers to the ability of the condyle tonegotiate around the disk. The disk’s recoilpotential is minimal in the pathologiccondition. The inferior surface of the diskis typically bulged and histologically is thesite of increased proteoglycan deposition.If pain and dysfunction persist despitetreatment of a coexistent parafunctionalhabit, surgery should be considered. Thesepatients are best managed with opensurgery and reduction of the obstructingportions of the articular disk. Diskoplasty,partial diskectomy, or full diskectomy maybe performed, depending on the degree ofdisk atrophy and deformation. Disk repo-sitioning should be considered only whenthe disk is minimally deformed and ofnear-normal length. Clinical indicators forsurgical intervention of this condition arerare. Some clinicians prefer to performarthroscopic disk-stabilizing proceduresusing suturing or sclerosing techniques.

The second clinical setting in whichinternal derangements are identified is thecondition of closed lock. Closed lock refersto an acute or chronic limitation of move-ment of the condyle owing to an intra-articular disturbance. Patients experienc-ing closed lock often complain of muscledysfunction secondary to efforts to reach abaseline mouth opening.

The coexistence of muscle dysfunctionand an internal derangement does notimply a relationship. A large segment of thegeneral population have minimal signs andsymptoms associated with internal derange-ments. Careful recording of the chief and

ancillary complaints is imperative, withattention being paid to the details of onsetand duration of facial pain and joint noise,timing of symptoms of facial tightness,inability to open or close the mouth, anddistribution of headaches. Concomitantsources of pain need to be identified andconsultations with neurology, otolaryngolo-gy, psychology, or general dentistry, asrequired, obtained. The history of previoustreatment is equally important.

There are usually a number of factorsthat are considered in the etiology ofclosed lock, including intracapsular andextracapsular inflammation and adhe-sions, muscle tension or spasm, disk dis-placement, synovial fluid viscosity, andreduction in synovial lubrication.

The closed lock phenomenon mayresolve spontaneously or gradually over aperiod of weeks to months. Hence, it isimportant to evaluate the patient on severalvisits to effectively note a response to non-steroidal anti-inflammatory agents andmuscle relaxants. In the absence of pain,many patients are able to tolerate the restric-tion in mouth opening, which graduallyimproves over several months to years.

MRI of the closed lock condition usu-ally demonstrates a displaced disk, withvarious degrees of deformation. In somepatients the disk appears in a normal posi-tion but is unable to be displaced down theslope of the eminence. Although not thesubject of this chapter, it suffices to saythat T1 and T2 (or gradient echo imaging)in sagittal planes is required to delineateintra-articular fluid, interstitial inflamma-tion, and disk morphology. Magnetic reso-nance images demonstrate that thecondyle is unable to displace the disk ante-rior enough to reach the apex of the emi-nence or beyond. On fast magnetic reso-nance or T2 images, inflammatory fluid orincreased vascularity appears as a high sig-nal intensity (Figure 50-1).

Adhesions associated with closed lockcannot be definitively identified on anMRI scan. They are suspected when there

JC_Saavedra
El reposicionamiento del disco debe ser considersado solo cuando el disco esta minimamente deforme o esta muy cerca de la normalidad.
JC_Saavedra
JC_Saavedra
CLOSED LOCK: limitacion aguda o cronica en los movimientos del condilo a causa de un problema intraarticular
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Surgery for Internal Derangements of the Temporomandibular Joint 991

is a confluence of the low signal intensitiesof the condyle and glenoid fossa withoutintervening intermediate signal intensity.Arthrocentesis followed by arthroscopiclysis of superior joint space adhesions,lavage, and manipulation are the treat-ments of choice for this condition. Opensurgical procedures are indicated whenarthroscopy has failed to resolve therestriction in opening. The choice of openprocedure largely depends on disk anato-my and position.

The third clinical setting is the internalderangement condition of disk displace-ment that reduces on opening and is asso-ciated with persistent preauricular painrefractory to nonsurgical therapy. This isthe most difficult of the three conditionsto treat and requires long-term therapywith control of parafunctional habits. Theclinician must ask whether the pain isoccurring from hypermobility caused bycontralateral hypomobility, acute orchronic separation of disk surfaces duringdisplacement and reduction, noncompli-ance with diet restrictions, or persistentparafunctional or work-related habits.There are indications for surgical inter-vention; however, it is this condition that

carries the greatest peril of being renderedinto the painful operated ankylosed jointafter several fruitless surgeries.

Arthrocentesis has supplanted arthro-scopic surgery as the most successful treat-ment modality. It should be attemptedbefore performing any open surgical pro-cedure. The type of open procedure is gov-erned by the degree of disk morphology.The key to arthroscopy is to remove thesource of the persistent inflammationincluding the vascular retrodiskal tissueand hyperplastic inflamed synovium.

Goals of Surgery

The general goals of any surgical interven-tion are to return the patient to a regulardiet, with some limitations, and to establishan adequate functional range of motion.Each patient’s complaints must be individ-ually analyzed, and specific outcomes setfor the operation. Postoperatively the sur-geon should evaluate the patient’s responseto therapy according to whether the patientfeels there has been a total eradication, sig-nificant reduction, or minimal reduction ofhis or her complaints, or no change orworsening of the condition. It is unreason-able for the surgeon to evaluate the results

of an operation on the basis of attainmentof a finite mouth opening. Many patientsare quite satisfied with reductions in theirmouth opening as long as their facial pain isrelieved. The goals for all surgical proce-dures should include preservation of artic-ular tissue to permit normalization andregeneration of synovium, and a restora-tion of the articular relations to permit thejoint structures to adapt and functionthrough an adequate range of motion. Theremodeled disk is only one element of thedegenerative process. Joint function may beasymptomatic and satisfactory in the pres-ence of various types of internal derange-ment. Thus, surgically returning a displaceddisk to the ideal position found in a healthyjoint may not be appropriate for an indi-vidual patient. To illustrate this point, onewould not reposition a disk in a joint inwhich the articular tissue is so severelydamaged that it is incapable of healing. Inthis situation removing the disk is recom-mended. Repositioning the disk is recom-mended in the patient with minimalchanges in the joint structures, in whomsymptoms have persisted despite nonsurgi-cal and arthroscopic intervention. As indi-cated above, this condition is indeed rare.

Additional magnetic resonance andarthroscopic information about the struc-ture and function of the joint in healthand disease is needed to establish reliableindicators and predictors of surgical out-come.

Surgical Approaches

The classic surgical approaches to the TMJmay be classified as preauricular, endaural,and postauricular. The choice of approachis usually a matter of surgeon’s preferenceand is based on his or her ability and expe-rience. Cosmetic considerations may alsoinfluence the choice of approach.

Surgical Anatomic Considerations

Anterior to the auricle, the auricularisanterior and superior muscles overlie the

FIGURE 50-1 A, T1-weighted sagittal magnetic resonance image demonstrating a dislocated disk. Notethe low signal intensity, which represents a portion of the deformed disk (arrow). B, Fast imaging(GRASS [gradient recalled acquisition in steady state]) of the same section demonstrates the presence ofextra-articular and intra-articular fluid or an increase in vascularity in the anterior regions of the joint.These changes may be partly responsible for the closed lock phenomenon.

A B

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superficial temporalis fascia and the tem-poralis fascia. These muscles are incised inthe classic preauricular and endauralapproaches. The fascia superficial to themuscles is thin and a dull white. This layeris confluent with the galea aponeuroticaabove and the parotideomasseteric fasciabelow. The temporalis fascia is a toughfibrous connective tissue structure, substan-tially thicker than the overlying superficialfascia. It is stark white and extends from thesuperior temporal line of the temporal boneto the zygomatic arch. The deep surface fur-nishes one of the origins of the temporalismuscle. Inferiorly, at a variable distance, thefascia splits into two well-defined layers(Figure 50-2). The outer layer attaches to the

lateral margin of the superior border of thezygomatic arch, and the inner layer to themedial margin. A small quantity of fat, thezygomatico-orbital branch of the temporalartery, and zygomaticotemporal branch ofthe maxillary nerve are located between thefascial layers. The splitting of the fascial lay-ers is most noticeable at the level of thezygomatic arch. Posteriorly, superior to theglenoid fossa, the separation is not as well-defined (Figure 50-3).

The superficial temporal vessels aretypically located in the superficial fasciabelow the auricularis anterior muscle.The vessels are often visible, invested inthe superficial fascia without incising themuscle. The superficial temporal vein liesposterior to the artery and the auricu-lotemporal nerve immediately behindthe vessels. The superficial temporal ves-sels and auriculotemporal nerve appearto take on a horizontal course once theflap is fully developed and reflectedanteroinferiorly.2

Numerous authors have studied thefacial nerve’s anatomic relations to deter-mine clinically applicable landmarks forits main trunk, temporofacial division,and temporal branches. Al-Kayat andBramley noted that the facial nervebifurcated into temporofacial and cervi-cofacial components within 2.3 cm(range 1.5–2.8 cm) inferior to the lowestconcavity of the bony external auditorycanal and within 3.0 cm (range 2.4–3.5 cm) in an inferoposterior directionfrom the postglenoid tubercle.3 The tem-poral nerve branches lie closest to thejoint and are the most commonly injuredbranches during surgery. These nervesare located in a condensation of superfi-cial fascia, temporalis fascia, and perios-teum as they cross the zygomatic arch.The most posterior temporal brancheslie anteriorly to the postglenoid tubercle.Their location was measured by Al-Kayatand Bramley as 3.5 ± 0.8 cm from theanterior margin of the bony externalauditory canal (Figure 50-4).3

Thus, the two potential sources offacial nerve injury are dissection anteriorto the posterior glenoid tubercle where thetemporal branches cross the arch, andaggressive retraction at the inferior marginof the flap where the main trunk and tem-porofacial division are located.

Preauricular Approach

Historically, a myriad of preauricular inci-sions have been proposed. Many of theearlier designs afforded good access butincreased the risk of facial nerve injuryand compromised esthetics. The preauric-ular incisions used today are essentiallymodifications of the Blair curvilinear orinverted-L incision.4 This approach hasbecome the favorite chosen by oral andmaxillofacial surgeons. The technique isan incision commencing from within thetemporal hairline and extending inferiorly

FIGURE 50-2 Coronal section at the level of thezygomatic arch. Two well-defined layers oftemporalis fascia are noted (arrows).

FIGURE 50-3 Coronal section at the level of theglenoid fossa. The splitting of the temporalis fas-cia is not as well-defined (broken line).

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into a preauricular crease immediatelyanterior to the auricle. The exact lengthand decision to incorporate an anteriortemporal extension are governed largelyby the nature of the surgical procedure.For some surgeons, the approach fordiskectomy requires a smaller incisionthan that for diskoplasty.

The incision is approximately 3 to 4cm in length and consists of two limbs: asmall superior curved limb (1–2 cm) andan inferior vertical limb anterior to thetragus (variable distance approximately1–2 cm) (Figure 50-5). The junction ofthese limbs is the site of attachment of thesuperior aspect of the helix to the tempo-ral tissue. The extent of the superior limbof the preauricular incision is dictated bythe amount of access required, which maynot be determined until the dissection hasreached the lateral TMJ ligament and cap-sule. The incision is usually not extendedas inferiorly as the lobule of the ear.

The incision should be placed poste-riorly to the superficial temporal vessels

and auriculotemporal nerve and within apreauricular crease. The skin and subcu-taneous tissues are incised the length ofthe entire incision. The deeper dissectionis begun in the temporal region bysharply dissecting progressively throughthe auricularis anterior and superficial

fascial layers to the stark white tempo-ralis fascia (Figure 50-6). A retractor isplaced on the anterior flap, and tension isapplied in a forward direction. The dis-section over the zygomatic arch isaddressed. The anatomic layers in thisregion are usually not clearly defined.There is a condensation of tissues con-sisting variably of the auricularis interi-or, superficial fascia, temporalis fascia,periosteum, and occasionally cartilage.This tissue is incised to the level offibrous connective tissue. A retractor isplaced in the incision opposite the tra-gus, and forward traction is applied tothe flap. This results in the definition of acleft between the perichondrium andcartilage of the external auditory canaland the parotideomasseteric fascia. Theperichondrium is followed medially withsharp dissection (Figure 50-7). Careshould be exercised not to proceed per-pendicularly to the skin surface, as theexternal auditory canal inclines antero-medially at approximately 45˚ to the sur-face. The dissection is continued alongthe outer surface of the external auditory

4

2 3

1

FIGURE 50-4 Landmarks for the location of the temporal branches and main trunk of the facialnerve: (1) the distance between the anterior margin concavity of the meatus to the zygomatic arch (3.5 ± 0.8 cm); (2) the distance between the inferior margin of the meatus to the trunk (2.3 ±0.28 cm); (3) the distance between the postglenoid tubercle to the main trunk (3.0 ± 0. 31 cm); (4) the distance from the tragus to the facial nerve trunk is variable.

FIGURE 50-5 Preauricular incision.

FIGURE 50-6 The preauricular incision has been carriedsharply through the skin, subcutaneous tissue, superficialtemporal fascia, auricularis anterior and superior, and outerlayers of the temporal fascia. The flap is reflected anteroinfe-riorly, revealing the inner layer of the temporal fascia.

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canal until the lateral TMJ ligament is reached.

When the condyle and its overlyingtemporomandibular ligament are palpated,the flap is reflected inferiorly and anteri-orly forward with a combination of sharp

and blunt dissections. Scissors may beused to cut some fascial attachments tothe lateral TMJ ligament. The blades ofthe scissors are held parallel to the liga-ment to ensure that the joint is not vio-lated. The flap is reflected as far forwardas the midportion of the anterior tuber-cle. The surgeon can now see the bulgingof the lateral pole of the condyle undercover of the lateral ligament and capsule.Gentle manipulation of the jaw to causemovement of the condyle helps to orientthe surgeon. The deep surface of the flapand the tissues overlying the zygomaticarch may be touched with a nerve stimu-lator to ascertain the location of the facialnerve. Retraction is accomplished using aself-retaining retractor (eg, cerebellarWeitlaner or a Dolwick-Reich) placedbetween the flap and the perichondrium.A small right-angled retractor may beplaced at the inferior portion of the flap(Figure 50-8).

Endaural Approach

Rongetti described a modification of Lem-pert’s endaural approach to the mastoidprocess for surgical improvement of oto-sclerosis, for approaching the TMJ.5,6 Theendaural incisions employed today eitherincorporate the anterior wall of the exter-nal auditory canal, or the tragus, or simplythe skin overlying the mental aspect of thetragus (Figure 50-9).

The incision begins well within theexternal auditory meatus at the superiormental wall. At this level the incision ismade down to the bone and extended in acurvilinear fashion upward hugging theanterior helix (see Figure 50-9). Itbecomes less penetrating as it approachesthe superior surface, ending at about thelevel of the inferior tragus. The incision isdeepened to the level of the temporalis fas-cia. The incision is now continued inferi-orly, with the knife in continuous contactwith the tympanic plate, to make a semi-circular incision to the inferior point ofthe meatus. The incision is then continued

FIGURE 50-7 The parotideomasseteric fascia issharply dissected from the perichondrium of theexternal auditory canal (broken line).

FIGURE 50-8 Retraction is accomplished byusing a self-retaining retractor positionedbetween the external auditory canal and flapand a right-angle retractor at the interior por-tion of the flap. The condyle (dotted line) isnoted under the lateral TMJ ligament and/orsimply the lateral capsule depending on thedepth of the reflection.

FIGURE 50-9 A–C, Endaural approach accord-ing to J. R. Rongetti. Adapted from Rongetti JR.5

A

B

C

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Surgery for Internal Derangements of the Temporomandibular Joint 995

anteroinferiorly to fall into the incisuraintertragica, ending just before itapproaches the surface. The application offorward traction on the inner aspect of thetragus assists the surgeon in completingthe incision. Sharp dissection is carrieddeeply for some distance along the peri-chondrium. The flap is then reflected enmasse anteroinferiorly off the lateral cap-sule and ligament.

The advantages of this incision lie inits excellent access to the lateral and pos-terior aspects of the joint, good exposureof the anterior aspect, and its estheticvalue. The access afforded through thisapproach is equal to that obtainedthrough the preauricular approach. Dis-advantages lie in the potential for peri-chondritis and an esthetic compromise iftragal projection is lost.

Postauricular Approach

In the postauricular approach the incisionis made posterior to the ear and involvesthe sectioning of the external auditorymeatus.7 Excellent posterolateral exposureis afforded with this technique. The flap,once reflected, contains the entire auricleand superficial lobe of the parotid gland. Aperimeatal approach combining thepreauricular and postauricular incisionshas also been described.8,9

The incision in the postauricularapproach begins near the superior aspectof the external pinna and is extended tothe tip of the mastoid process. The supe-rior portion may be extended obliquelyinto the hairline for additional exposure.The incision is made 3 to 5 mm paralleland posterior to the postauricular flexure(Figure 50-10). The dissection is per-formed through the posterior auricularmuscle to the level of the mastoid fascia,which is contiguous with the temporalisfascia. A combination of blunt and sharpdissections is used to isolate the cartilagi-nous portion of the external auditorycanal. A blunt instrument is placed in theexternal auditory canal to assist in the

transsection of the external auditorycanal. The transsection may be partial orcomplete, depending on the need forexposure. The incision should leave 3 to4 mm of cartilage on the medial aspect topermit adequate reapproximation of thecanal (Figure 50-11). This techniquehelps to prevent meatal stenosis. Theincision is carried through the outerlayer of the temporalis fascia, continuinginferiorly, reflecting the parotideomasse-teric fascia off the zygomatic arch andlateral TMJ ligament (Figure 50-12). Aself-retaining retractor is used to main-tain exposure. The advantages of thepostauricular approach lie in the pre-dictability of the anatomic exposure.Dissection to the joint is rapid with min-imal bleeding. The approach offers analternative for a patient who has had pre-vious procedures in this region. Thisapproach may not be desirable in thepatient susceptible to keloid formation,owing to the potential for a keloid todevelop in the meatus. Meatal atresia hasbeen reported with this technique.10 Therisk of facial nerve injury is not eliminat-ed. Paresthesia in the area of the posteri-or aspect of the auricle usually occursand lasts 3 to 4 months.

Capsular Incisions

Hori\zontal Incision Over the Lateral Rim

of the Glenoid Fossa The lateral liga-ment, capsule, and periosteum are reflectedinferiorly en masse. Diskal or posteriorattachment connections, or both, to the lat-eral capsule are dissected sharply with scis-sors to the level of the condylar neck (Fig-ure 50-13A). Posterior dissection isperformed diligently to avoid severing theretrodiskal tissue. This portion of the dis-section exposes the superior joint space(Figure 50-13B). A Freer septum elevator

FIGURE 50-10 Postauricular approach. Theincision is placed 3 to 5 mm parallel and posteri-or to the postauricular flexure.

FIGURE 50-11 The external auditory canal is sec-tioned, leaving 3 to 4 mm of cartilage on the medi-al aspect to assist reapproximation of the canal.

FIGURE 50-12 The external auditory canal hasbeen sectioned and the flap retracted forward.

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may be used to define and explore thespace. The posterior attachment and diskattachments are then severed sharply at thelateral pole of the condyle from within thedeveloped flap. The Freer septum elevatoris used to reflect the posterior attachmentand disk superiorly off the head of thecondyle to expose the inferior joint space. Aperiosteal elevator may be used to stretchthe capsule and lateral ligament flap out-ward to form a pocket (Figure 50-13C).

There is a risk of reflecting the fibrousconnective tissue that lines the glenoidfossa when this approach is used (Figure50-14A). The surgeon may form the incor-rect assumption that he or she is strippingadhesions from the temporal bone whiledefining the space. The result may be a

partial or total synovectomy of the superi-or joint space. Prearthrotomy arthroscopicexaminations have alerted clinicians tothis error. The ability of the pathologicjoint to regenerate this synovium andfibrous connective tissue layer has notbeen determined.

Horizontal Incision Below the Lateral

Rim of the Glenoid Fossa A no. 11 blademay be used to puncture into the superiorjoint space at the level of the lateral disko-capsular sulcus (Figure 50-14B). Theopening is then lengthened anteriorly andposteriorly using sharp-pointed scissors. Adissection technique, similar to thatdescribed in the foregoing approach, isused to define the superior joint space. A

dissection is then carried inferiorly remov-ing the attachment of the capsule to thedisk and exposing the inferior joint space.There is less risk of injury to theretrodiskal tissue with this approach; therisk to the fibrocartilage is also reduced.This is the approach I favor.

Horizontal Incisions Above and Below the

Disk The horizontal approach aboveand below the disk (Figure 50-14C) leavessome of the capsule and ligament attachedto the disk or remodeled retrodiskal tissue.

L-Shaped Incision A horizontal incisionis made at or below the lateral rim of theglenoid fossa. The horizontal incision isthen joined by either an anterior (Figure50-14D) or posterior (Figure 50-14E) ver-tical extension. The posterior vertical inci-sion carries the risk of severing theretrodiskal tissue. The anterior verticalincision should not be placed farther ante-riorly than the tubercle to avoid injury tothe facial nerve. The capsule and ligamentare then reflected either anteroinferiorly orposteroinferiorly.

T-Shaped Incision A horizontal incisionis joined by a vertical incision to create aT-shaped incision over the midportion ofthe glenoid fossa (Figure 50-14F).

Cross-Hair Incision Dissection of theposterior attachment of the lateral liga-ment and capsule may be tedious with thecross-hair incision (Figure 50-14G).

Open-Sky Incision In the open-sky inci-sion two horizontal incisions are joined bya central vertical incision (Figure 50-14H).

Vertical Incision After a vertical incision ismade, the capsular flaps are reflected anteri-orly and posteriorly to expose the posteriorattachment and disk (Figure 50-14I). Clo-sure of the capsule is often difficult toattain following open surgical procedures.When diagnostic arthroscopy precedes the

FIGURE 50-13 A, Entry into the superiorjoint space following its distention with fluid.A no. 11 blade incises the lateral capsule andligament (broken line). Care is maintainednot to prolong the incision posteriorly toavoid injuring the retrodiskal tissues. B, Theincision is prolonged posteriorly using babymetzenbaum scissors. C, The horizontal cap-sular and ligament flap is developed inferior-ly and the diskal insertions sharply dissected(broken line). The inferior joint space isdefined by incising along the superolateralaspect of the condyle. A Freer septum eleva-tor is used to define the joint spaces.

A B

C

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Surgery for Internal Derangements of the Temporomandibular Joint 997

arthrotomy, the inflow and outflow portsviolate the capsule, making watertight closure extremely difficult. Support for thelateral ligament can be obtained by raisinga temporalis muscle and fascia flap, about 2 cm in length, pedicled inferiorly, androtated inferiorly over the lateral rim of theglenoid fossa and sutured to the lateralcapsular tissue. The pedicle stabilizes theflap but has not been shown to containnutrient vessels. Closure of the capsulemay not be critical to the success of the

diskectomy procedure, and in some casesthe closure may restrict mandibularmotion.11,12 However, closure of the cap-sule and ligament after disk repositioninglends stability to the diskorrhaphy.

Operative Procedures

A concerted comparative evaluation ofdifferent surgical techniques is difficultbecause for many years there was no uni-form set of criteria for selection of patientsor compilation and evaluation of results.

Criteria and guidelines for disk surgerywere initially developed in 1984 by theAmerican Association of Oral and Max-illofacial Surgeons (AAOMS).13 The crite-ria were established through a literaturereview and consensus. In 1990 a standardsand criteria document was published bythe AAOMS.14 The document establishedindications for surgery, identified markersfor favorable and unfavorable results, andoutlined risk factors. These publicationshave laid the groundwork for peer review.

FIGURE 50-14 Capsular incision designs: A, horizontal incision over the lateral rim of the glenoid fossa; B, horizontal incision below the lateral rim of the glenoid fossa; C, horizontal incisions above and below the disk; D and E, L-shaped incision; F, T-shaped incision; G, cross-hair incision; H, open-sky incision; I, vertical incision. The lateral pole of the condyle and lateral aspect of the remodeled posterior attachment (broken lines) are illustrated.

A B C

D E F

G H I

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998 Part 7: Temporomandibular Joint Disease

Disk-Repositioning Procedures

The goal of disk-repositioning procedures isto relocate the disk so that its posterior bandcan be returned to the normal condyle-disk-fossa relationship. Essentially, the reposition-ing places the posterior band over the supe-rior or superoanterior surface of thecondyle. This retropositioning is accom-plished by one of three procedures: plicationin which the remodeled posterior attach-ment is folded on itself and the lateral tissuesare approximated (Figure 50-15); full-thickness excision in which a wedge-shapedportion of the posterior attachment isremoved and the lateroposterior tissues areapproximated (Figure 50-16); or partial-thickness excision in which the superior lam-ina of the retrodiskal tissue and posteriorattachment are removed, without violation ofthe inferior joint space, and the lateroposteri-or tissues are approximated (Figure 50-17).

When the disk displaces, the patholog-ic changes are not seen uniformly through-out the entire lateromedial extent of thejoint. Typically, the medially displaced diskmust be rotated posterolaterally to achievea correct condyle-disk-fossa relation;therefore, a greater amount of tissue is pli-cated or excised laterally rather than medi-ally. Rarely, the disk may be displaced in thelateral direction, in which event the reversewould be true.

The technical improvements in TMJarthrography in the 1970s stimulated inter-est in correcting disturbances in thecondyle-disk-fossa relations,15 and the

concept that disk repair procedures were aviable answer to many cases of TMJ dys-function was re-introduced.16 Reports onthe outcome of disk repair procedures haveindicated an 80% or greater successrate.17–19 The latter assumes an accuratediagnosis has been made. Surgeon diag-nostic acumen has evolved with time.Although the results of the procedures mayhave been good in the 1980s, readers mustbe cautious as the indications for perform-ing the procedure have changed and hencethe outcomes may be misleading given thenew subset of surgical candidates.

The histologic basis for performingsurgery within vascular retrodiskal tissuewas described in animals by Wallace andLaskin and by Zeitler and colleagues.20,21

Synoviocytes play an important role in thehealing process. Stimulated by inflamma-tion, synoviocytes proliferate and migrateto fill the surgically created gap in the tis-sues.22–24 The synoviocytes produceground substance and collagen fibers andphagocytose the debris. The degree of tis-sue vascularity and the distance from cap-sular and synovial vasculature have alsobeen described as important factors in thehealing process. 25,26

Extrapolations to the clinical situationmust be made from these results as an ani-mal model for TMJ pathology is lacking.In the human, variable decreases in thevascularity of the remodeled posteriorattachment are believed to occur with anincreasing duration of displacement andload. The disk-repositioning techniquesthus involve a repair in the pathologicremodeled retrodiskal tissue with a vari-able degree of vascularity. The primarysource of nourishment to the repositioned

FIGURE 50-15 Disk repositioning achieved through plication of the posterior attachment. Retention of diskposition is through sutures to the lateral capsule ligament. A, Preoperative location. B, Postoperative location.

A B

FIGURE 50-16 Disk repositioning achieved through a full-thickness excision of the posterior attach-ment. Retention of disk position is through sutures placed on posterior and lateral margins. A, A clamphas been placed over the posterior attachment. The arrow represents the direction of pull of the clampto complete the incision and reveal the condylar surface. B, View from above demonstrating the wedge-shaped resection (arrow indicates the direction of closure).

Disk

Condyle

A B

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Surgery for Internal Derangements of the Temporomandibular Joint 999

disk appears to be through the synoviumon the medial aspect of the disk and pos-terior recesses of the joint spaces. Thus, acritical aspect of the successful surgicalrepair in the retrodiskal tissue appears tobe the rapid migration of synoviocytes tothe area of the surgical repair. Smith andWalters followed up 12 patients for 1 yearand reported success suturing tears in theavascular portion of the disk.27 Others,however, have reported that suturing any-thing but vascularized tissue results in fail-ure of the repair.20,28

With an increasing displacement ofthe disk, the retrodiskal tissue comes intocontact with the condole and sustainsincreasing loading. The loading results indecreased vascularity of the retrodiskal tis-sue. With the reduction in retrodiskal tis-sue vascularity, this tissue becomes trans-formed into a pseudodisk. MRI ofchronically displaced retrodiskal tissuesdemonstrates a signal intensity of the tis-

sue that resembles the disk. In fact, radiol-ogists may inaccurately describe a diskfragmentation because only a portion ofthe displaced disk may display its originalsignal intensity. The remainder, owing toalterations in the glycoprotein distributionand hence the attraction of water, demon-strate a moderate signal intensity. Withincreasing displacement of the disk, thesuperior joint space does not accommo-date for the increase in length of theretrodiskal tissue. Rather, the disk under-goes atrophy, deformation (buckling), andabsorption into the anterior capsule.These changes can make anatomic reposi-tioning of the disk impossible.

Disk repositioning without diskoplas-ty is indicated in the following instances:

• There is minimal disk displacement • The disk is of near-normal length• The disk structure is near normal

(bow-tie)

The rationale behind repositioning isfounded on the belief that the diseaseprocess is reversible or can be halted bynormalizing the position of the disk. Inaddition, removal of the posterior attach-ment overlying the condyle is intended toremove a source of localized inflamma-tion. The repositioned disk facilitatesmovement of the condyle previouslyblocked by the displaced disk, providesjoint stabilization, and improves articularcartilage nutrition and lubrication. More-over, the rationale is that the workload ofthe masticatory muscles is reduced whenthe obstructing disk is repositioned.

Before performing disk-repositioningprocedures in patients with satisfactorydisk morphology, adequate trials of non-surgical therapy should be undertaken todetermine whether the patient can bemade symptom free despite disk displace-ment. In 1989, reports were publisheddemonstrating, by postarthroscopic MRI,persistent disk displacement despite theresolution of pain and increase inmandibular mobility.29,30 These reports,

and the appearance of anterior disk dis-placement in patients without any historyof TMJ symptoms, support the executionof nonsurgical therapy prior to decidingwhether it is necessary to perform disk-repositioning surgery.

Deformation of the disk in all planes isan important feature to recognize whenplanning a repositioning procedure. Whena bulge-shaped disk is of appropriatelength and can be repositioned, a disko-plasty may be performed to minimize thechange in the occlusion.31 It has beenreported that during function, the fiberarrangement and proteoglycan distribu-tion of the repositioned disk change tothose of a normal disk and that diskoplas-ty therefore would be unnecessary.32 Moreevidence is still required to substantiatethese changes.

In general, the limiting factor to diskrepositioning is the degree of lateral diskatrophy or resorption. Despite severe lat-eral atrophy, the most medial aspect of thedisk may have a normal length and shape(Figure 50-18). Disk shortening may pre-clude disk repositioning without an exten-sive release of the anterolateral disk attach-ments, calling into question the procedureof repositioning.

Disk Repositioning and Diskoplasty Arosette-shaped disposable orthopedicmeniscus knife, typically used for orthope-dic arthroscopic procedures, is used toeffect a release of the disk from its mostanterior and lateral attachments (Figure50-19). This is accomplished by gentlyprodding the knife along the insideperimeter of the capsule (Figure 50-20). Asthe dissection is performed under cover ofthe capsule, there is no danger of injuringthe facial nerve. Disk mobility is evaluatedby applying posterolateral traction with aforceps (Figure 50-21). A DeBakey bulldogvascular clamp is inserted to the mediallimit of the posterior attachment andguided posteriorly as far as possible in theglenoid fossa (see Figure 50-20B). The

FIGURE 50-17 Disk repositioning achievedthrough a partial-thickness excision of the supe-rior lamina of the retrodiskal tissue. The inferiorjoint space is not violated. A, Outline of a par-tial-thickness excision of the superior lamina. B,Excision is closed, resulting in posterior reposi-tioning of the disk.

A

B

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1000 Part 7: Temporomandibular Joint Disease

clamp greatly assists in the control of hem-orrhage from the retrodiskal tissue, stabi-lization of the posterior attachment dur-ing tissue excision, and stabilization of theposterior attachment during suturing.33

The design of the instrument minimizestissue damage. A wedge of remodeled pos-terior attachment is excised, leaving a 1 mm margin anterior to the beaks of theclamp. This permits suturing of the disk tothe retrodiskal tissue without removal ofthe clamp. Range of motion is then veri-fied. Tissue forceps are used to stabilizeand slightly evert the disk so that the infe-

rior surface may be sculpted with menis-cus knives (Figure 50-22). The tissue isclosed with nonresorbable suture on an S-2 spatula needle (Figure 50-23). Once thedisk has been sutured into its new posi-tion, its lateral rim is sutured to the lateralcapsule ligament.

Operative difficulties with the reposi-tioning techniques include control ofhemorrhage from the retrodiskal tissueand access to the medial aspect of thefossa. Bleeding may be controlled by usingthe DeBakey clamp before sectioning theposterior attachment. Access to the medialaspect of the joint is greatly improvedwhen the anterior attachment is released,permitting the surgeon to draw the diskoutward posterolaterally while it remainspedicled to the medial attachment. Inter-estingly, the problem of access was one ofthe impetuses for combining disk reposi-tioning with a condylar and/or eminentialarthroplasty.

Disk Repositioning and Arthroplasty

Several operators have advocated combin-ing an arthroplasty of the condyle or emi-nence with disk repositioning.16,32,34–36

Arthroplasty reduces the amount of pos-terolateral repositioning required andtherefore permits repositioning of anatrophic disk (Figure 50-24). The currenttrend, however, is to avoid removal of anynormal articular bone since the postoper-ative healing phase already involves someloss of bone substance, which may beadditive and result in occlusal distur-bances. In addition, postoperative bleed-ing from cut bone surfaces into the jointcan result in fibrous adhesions of the diskor fibrous/bony ankylosis of the joint.

A 2 to 4 mm condylar-eminencearthroplasty procedure can be performedwith rotary or hand instruments. Handinstruments such as fine chisels are prefer-able to avoid heat generation (Figure 50-25). Bone files should be used judiciouslybecause, once the compact bony layer isinterrupted, the trabeculae of bone can be

easily and rapidly removed. A periostealelevator may be used to burnish sharpedges. Care should be exercised not toexaggerate the arthroplasty in the lateralcondylar regions while accessing the medi-al condylar region. In some cases anarthroplasty of the eminence is essentiallya lateral tuberculectomy for access anddecompression of the anterior recess ofthe superior joint space (Figure 50-26).36,37 Disk repositioning is then performedthrough the plication or excision tech-nique. The capsule is closed in the custom-ary fashion. Intermaxillary fixation ortraining elastics are used for 1 to 3 weeksto allow muscular adaptation and dentalcompensations to occur.

Repair of Perforated Posterior Attachment

Perforations rarely occur within the diskproper but rather within the lateral third ofthe remodeled posterior attachment.38,39

FIGURE 50-18 A series of sagittal histologic sec-tions through a joint, demonstrating partial diskdisplacement. Note the change in disk length andmorphology as one moves from lateral (A) tomedial (C)(hematoxylin eosin stain; macroscop-ic section).

A

B

C

FIGURE 50-19 Orthopedic arthroscopic knifes(blade handles are not illustrated): A, rosette mini-meniscus curved; B, curved (right or left avail-able); C, sickle; D, retrograde.

D

C

B

A

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Surgery for Internal Derangements of the Temporomandibular Joint 1001

When the disk is perforated, it may be sec-ondary to a developmental rather than apathologic process. Condylar overgrowthoften occurs in the areas of the perfora-tions; therefore, an arthroplasty is frequent-ly performed in conjunction with the pro-

cedure. The repaired remodeled retrodiskaltissue is intended to maintain the shape ofthe articular surface and to prevent ankylo-sis. Repair of a perforation without reposi-tioning the disk is successful only if the diskis atrophied and is not an obstruction to

condylar movement. This procedure is per-formed rarely and only in those patientsrefractory to intra-articular steroid injec-tion, arthrocentesis, or arthroscopy.

Management of Small Perforations Whenprimary closure of a small perforation (1–3 mm) is planned, the atrophic displaceddisk is repositioned posteriorly to only aminor degree. If the disk is to be fully repo-sitioned, the margins of the perforationshould be excised and the posterior attach-ment on the posterior edge of the diskapproximated to the tympanic portion ofthe retrodiskal tissue. Anterolateral release ofthe diskal attachments is usually necessary tomobilize the disk posteriorly. The margins ofthe perforation are oversewn in a straight-line fashion with a nonresorbable material.The repair procedure is often performed inconjunction with an arthroplasty to reducesharp bony spurs that may be present.

Management of Large Perforations

Large perforations are usually grafted afterexcision of the edges. The disk is not repo-sitioned. In many cases this procedure is apartial diskectomy (Figures 50-27 and 50-

Retrodiskal tissue

Disk

Beaks of clamp

FIGURE 50-20 A, View of partially reducing disk displacement from above and slightly posterior.Note that when the medial portion of the disk is in the normal position, that portion of the disk maybe preserved. Note the path of incision of the crescent-shaped mini-meniscus knife (broken line). B,Positioning of the beaks of the DeBakey clamp on retrodiskal tissue.

A

B

Posterior attachment

Capsule

"Bunched up" posterior attachment

FIGURE 50-21 A and B, The pathologicposterior attachment is grasped with a for-ceps, and posterior traction is applied(arrow) to check disk mobility and thepotential for surgical repositioning.

A B

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1002 Part 7: Temporomandibular Joint Disease

28). The graft material is laid over the per-foration and posterior attachment. Auto-grafts (dermal) and homografts have beenused (Figure 50-29). The free edges of thegraft are sutured to the underlying poste-rior attachment and disk. Typically, medi-al sutures are difficult to place. A suturingtechnique using an S-2 spatula or RD-1needle is recommended.

Disk-Removal Procedures

Partial Diskectomy The partial diskecto-my procedure is used to correct partialreducing disk displacement.12,40 The goalof the procedure is to excise the patholog-ic posterior attachment and that portionof the displaced atrophic/resorbed diskthat represents an obstruction or is pre-sumed to be responsible for terminal jolt-ing. The portion of the disk that is proper-ly positioned, usually the medial aspect ofthe disk, is left in place. This procedurewas recently re-described under the termdisk reshaping.41 Kondoh and colleaguesreported a favorable 5-year outcome intheir patients.41 The absence of portions ofthe TMJ disk may predispose the joint toareas of fibrous or bony ankylosis. The

postoperative import of ankylosis largelydepends on the efficacy of physical thera-py, the surface area affected, and ability ofsynovium to regenerate.

The rationale for electing to performa partial diskectomy rather than a diskrepositioning is based on the belief thatthose factors responsible for the initialdisk displacement are often not ade-quately controlled or identified and thuseventually cause redisplacement of thedisk. Usually osseous remodelingchanges have occurred to accommodatethe change in disk position. Sprinzdescribed the histologic basis for the par-tial diskectomy procedure.42 Surgicallycreated defects within the rabbit menis-cus healed uneventfully if the defects

Retrodiskal tissue

Underside of disk

Knife

FIGURE 50-22 Diskoplasty is performed follow-ing wedge resection of the pathologic posteriorattachment. The disk is slightly evened, and anarthroscopic orthopedic knife is used to sculpt theinferior surface of the bulge-shaped disk. TheDeBakey vascular clamp is in place. Note theprotruding edge of the posterior attachment(arrow) used for reapproximation to the diskand lateral capsule.

1

2

3

45

FIGURE 50-23 Disk reapproximation: A, simple posterior and lateral sutures; B, layered closure of thesuperior and inferior lamina; C, figure-of-8 closure; D, the order of passage of the figure-of-8 suturelabeled 1 to 5.

A B

C D

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Surgery for Internal Derangements of the Temporomandibular Joint 1003

were close to the vascular periphery. Inthe rabbit knee meniscus subjected topartial meniscectomy, the replacementtissue appeared to be derived from thesynovium of the articular capsule.43

Preoperative confirmation of a partialreducing disk using MRI or arthrotomo-graphic images is imperative in decidingwhether to perform this procedure. Afterexposure of the joint spaces, the DeBakey

clamp is inserted to the medial limit of theposterior glenoid fossa. Retrodiskal tissueand displaced portions of the disk are then

FIGURE 50-24 A–C, Disk repositioning with arthroplasty according to Walker and Kalamchi. The disk is sutured to the condyle stump. Adapted from Walker RV andKalamchi S.32

A B C

FIGURE 50-25 Condylar arthroplasty using an osteotome. An osteophyte hasalready been excised. The direction of the osteotome (arrow) is indicated in orderto skim the condylar surface. Self-retaining and right-angle retractors are in place.

Posterior attachment

FIGURE 50-26 Lateral tuberculectomy may beperformed to acquire access to the anterior gle-noid and eminence regions (broken line indi-cates bone to be excised and arrow indicatesdirection of osteotome).

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1004 Part 7: Temporomandibular Joint Disease

removed in a piecemeal fashion using oto-logic basket forceps (see Figure 50-27). Thetissues are removed until the properly posi-tioned disk is noted. The surgeon may thengraft the surgical site with an autologousdermal graft. The graft is sutured to a cuffof tissue left at the circumference of the sur-gically created perforation (see Figures 50-28 and 50-29). In some cases the surgeonmay elect not to graft the artificially createdperforation. Capsular and skin closures areaccomplished in the customary fashion.Following extirpation of the disk portion inquestion, joint movement is simulated toensure that there is smooth condylar move-ment in lateral and anterior planes. Theprocedure can produce excellent immediategratification to the patient and improvejoint function. However, complete smoothexcision of the inferior aspect of the disk isrequired to prevent reoccurrence. A perfo-ration is sometimes intentionally created to

remove the obstacle. The displaced disk isessentially changed to a displaced meniscus.The perforation is rarely problematic forthe patient as it is created anterior to thecondyle. The perforation repair describedearlier is performed over the head of thecondyle; such perforations can lead tochronic pain refractory to steroid injection.

Total Diskectomy Total diskectomy isthe procedure in which the remodeledposterior attachment and entire disk areexcised. It is the most extensively used andreported surgical procedure, having beenapplied from as early as the 1900s. Totaldiskectomy has been used to treat the fullgamut of internal derangements, withoutconsideration for the degree of displace-ment of disk morphology, with generallygood to excellent results.44–50

Despite the reported successes withdiskectomy,51–53 the more sophisticateddiskoplasty techniques supplanted thediskectomy during the 1970s to mid-1980s.51–53 In the 1980s diskectomybecame popular once again following theintroduction of implantable biomaterialsthat were used as disk replacements.

Diskectomy is indicated in those situ-ations for which disk repositioning is notfeasible because of disk atrophy, deforma-tion, or severe degeneration. A joint withan atrophied, deformed, or degenerateddisk cannot be rejuvenated because someof the associated pathologic changes—col-lagen fiber reorientation, increasedground substance, presence of elasticfibers in all disk zones, cartilaginousdeposits, and increased vascularity—areirreversible. The goal of surgery is to assistthe host to adapt to the pathology at handby removing the physical impediment tomovement and the pathologic posteriorattachment.

Bowman studied the results of totaldiskectomy in 52 patients followed over 3 months to 22 years.12 Thirty of hispatients were studied for 4 years or more.Subsequently, in 1986, Eriksson and West-

esson reported a follow-up (mean 29 yr)on 15 of Bowman’s patients.40 Bowman’sobservations, which have been corroborat-ed by others,10,54,55 form the basis of muchof the discussion that follows.

Total diskectomy deprives the joint ofthe posterior attachment and posterioraspect of the remodeled disk. In the dis-eased state these tissues serve as the shockabsorbers for the bony surfaces. The resid-ual “normal” synovium is responsible forthe lubrication and nutrition of the articu-lar surfaces. The absence of retrodiskal tis-sue may interfere with the normal flow anddiffusion of synovial fluid.56 With diskecto-my, the surgeon probably transforms ajoint into what more appropriately wouldbe described as two bones in close apposi-tion. As a result, several adaptive changes

Posterior attachment(partially removed)

Disk

FIGURE 50-27 Partial diskectomy. Midcondylar regionis illustrated. Bulge portions of the disk are excised in apiecemeal fashion using otologic basket forceps. Portionsof the excised disk partially excised are hatched exposingthe remodeled disk in cross-section.

Remodeled retrodiskal tissue

Condyle

Area of disk removed

Capsule

FIGURE 50-28 For repair of a large perforation, apartial diskectomy is performed first. A portion ofthe disk and the retrodiskal tissue may be retained.

Capsule

Graft overlaps retrodiskal tissue and disk remnant

FIGURE 50-29 A dermal graft covers the surgi-cally created perforation. The edges of the graftoverlay the disk, retrodiskal tissue, and lateralcapsule to assist in suturing.

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Surgery for Internal Derangements of the Temporomandibular Joint 1005

rapidly occur. These changes are reflectedin the manner in which the joint functionsand how it appears radiographically. Manyclinical examples of such a bony arrange-ment providing the patient with adequatepain-free function may be drawn from thereconstructive literature.

Clinicians often observe the loss orreduction of gliding motion in the jointwith nonreducing disk displacement. Inthis situation the joint behaves principal-ly as a ginglymoid joint. Initially there islimited translational capability. As heal-ing progresses and osseous remodelingoccurs, the rotational (hinge) movementbecomes minimal and the gliding motionpredominates. The patient must rapidlyregain mobility through prescribed phys-ical therapy to prevent the developmentof ankylosis.

Adult cartilage derives its nutrientssolely from synovial fluid. The prolongedcontact of bony surfaces following menis-cectomy may interfere with diffusion ofnutrients from the synovial fluid. Thedecreased diffusion of nutrients to carti-lage may result in the eventual resorptionof noncalcified cartilage.

After a diskectomy some masticatorymuscle and joint tenderness can be expect-ed for a variable period, extending fromseveral weeks to months. The patient atfirst favors mastication on the operatedside. Later, when healing is advanced, mas-tication is performed on the nonoperatedside. An opening deviation of as much as 8 to 9 mm may occur toward the operatedside. The deviation appears to be a normalcompensatory function secondary to theloss of posterior attachment and synovi-um, the change in the joint architecture,and areas of fibrous ankylosis. Counter-acting the lateral deviation actively or pas-sively causes pain in the operated joint.

Hypermobility of the nonoperatedjoint may develop or increase after diskec-tomy. Limitation of mandibular move-ment on the operated side appears to beresponsible for the hypermobility. The

hypermobility may be responsible forawakening symptoms of a quiescent inter-nal derangement. Capsular tighteningprocedures have been performed in con-junction with diskectomy to reducecondylar hypermobility (Figure 50-30).57–59 Physical therapy greatly assists thecontrol of the ipsilateral deviation andhence contralateral hypermobility.

Joint crepitations or “snappings” oftenoccur postoperatively. The snappings havebeen attributed to the condyle rubbing onresidual nonextirpated portions of thedisk and usually cease after severalmonths. Patients often report an alterationin their bite, although rarely as a majorcomplaint. The thicker the retrodiskal tis-sue removed, the greater is the anticipatedchange in occlusion. The sensation of analtered bite usually resolves within a weekto several months, with resolution ofintra-articular edema, clot retraction, anddental compensations. Occlusal equilibra-tion is rarely indicated.

There is considerable variation in theability of each patient and joint to adapt tothe postdiskectomy state. Individual fac-tors, such as inclination of the eminence,state of preoperative symptoms, loss ofmolar support, and amount of postopera-tive remodeling, do not seem to play a sub-stantial role.

Clinicians are often alarmed by thedegree of osseous remodeling observed

after a diskectomy. The morphologic andradiologic changes observed in the TMJconcur with those observed in experimen-tal diskectomy.41,60 After approximately 1 year the morphologic appearance of thecondyle and temporal bone appear similarto those observed in a typical arthrodialjoint, that is, there are planar (flat) articu-lar surfaces. This is reflected by the mannerin which the joint is observed to function.Agerberg and Lundberg described erosionof the articular surfaces and interruptionsof the cortical outline on transcranial radi-ographs.61 The osseous changes appearedprimarily in the lateral and anterior aspectsof the joint. The posterior aspects wereleast affected. Remodeling changes haveeven been identified in the lateral third ofthe contralateral (nonoperated) joint.62,63

However, this was not confirmed by Bow-man.12 Agerberg and Lundberg concludedthat the remodeling process stabilized after2 years.61 They used the term remodeling

and not osteoarthrosis to describe the radi-ographic changes because the osseouschanges occurred in the absence of symp-toms. The bony changes appear similar tothose that are observed longitudinally withchronic disk displacement, suggestive ofthe same mechanism. The rate of remodel-ing, however, is accelerated in the post-diskectomy state. A similar observation hasbeen made in the postmeniscectomyhuman knee joint.64

Articular disk

Origin of lateral fibers of lateral temporomandibularligament

FIGURE 50-30 Capsular tightening procedure as per Mar-tin and colleagues. The lateral ligament is reflected from thezygomatic arch (arrow) (A) and then sutured posterior to itsanatomic origin (B). Adapted from Martin BC et al.59

A B

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1006 Part 7: Temporomandibular Joint Disease

Diskectomy without Replacement Diskextirpation is facilitated when the atrophicdisk is severed from its anterior and lateralattachments and then retracted laterallyand posteriorly to complete the incisions.This approach permits the surgeon to veri-fy the ability of the disk to be repositionedposteriorly before excision. With severeatrophy of the disk, substantial resistanceto posterolateral traction is noted. A hemo-static clamp is positioned across the anteri-or attachment to serve as a guide plane forthe knife, which is used to sever the attach-ment lateromedially (Figure 50-31). As theposterior attachment demonstrates a vari-able degree of vascularity changes, theDeBakey bulldog vascular clamp orstraight mosquito clamp may be appliedhere before severing the posterior attach-ment. Next, a hemostat is used to applyoutward traction to the tissue to be extir-

pated (Figure 50-32). A meniscus knife isused to sever the medial attachments.When the remodeled posterior attachmentand disk are extirpated, the retrodiskal tis-sue is electrocauterized to control bleeding.Care is taken not to disrupt the fibrousconnective tissue lining of the fossa andcondyle. The morphology of the condyleand glenoid fossa often prevent excision inone piece. Incomplete excision of the pos-terior attachment over the lateral pole ofthe condyle may account for some cases offailure with diskectomy. After the disk andposterior attachment are excised, the sur-geon should verify that there is not a sig-nificant diaphragm of irregular posteriorattachment tissue that remains laterallyaround the head of the condyle.

With the disk and posterior attach-ment removed, mandibular range ofmotion is simulated by manipulating themandible in lateral and protrusive excur-sions. Joint noises, characterized as snap-pings, may indicate a disk remnant. Diskremnants are usually located on the medi-al aspect of the joint cavity. The surgeonshould remove all disk remnants thatappear to impede movement.

Disk Replacements

Autogenous, homologous, and alloplasticreplacements for the disk have been usedfollowing diskectomy to prevent or reduceintra-articular adhesions, osseous remodel-ing, and recurrent pain. In addition, theinterpositional material was believed todecrease joint noises by dissipating loadingforces on the osseous surfaces. The effective-ness of interpositional grafts in reducingadhesions, protecting the articular surfaces,and diminishing pain and postdiskectomyjoint noise has not been substantiated. Theuse of these materials is sporadic andaccording to operator preference.

The dermal graft may be harvestedfrom the buttock, upper lateral thigh,groin, or the inner aspect of the upperextremity. When the thigh is selected as thedonor site, a dermatome may be used to

raise the skin (0.30–0.38 mm) and thenthe dermis (0.46–0.51 mm). The der-matome width should be set to take thedermal graft 20 to 30% larger than isrequired to compensate for immediatecontraction of the graft. Bleeding in thedonor site should then be thoroughly con-trolled to prevent hematoma formationunder the skin, which is replaced over thedonor site. Adhesive strips may be applied,or the skin edges may be sutured with 5-0nylon. The surgical site is then dressedwith an occlusive dressing. Postoperativelythe donor site should be checked for sero-ma formation during the first 48 hours.

Alternatively, when size requirementsare minimal, the graft may be harvestedfreehand. An elliptic wedge of epidermisand underlying dermis is harvested. Theunderlying surface of the dermis must bedefatted before being implanted. Thedefatted graft is trimmed and sutured tothe retrodiskal tissue and the anterior andlateral capsular attachments.

The dermal graft is believed to func-tion as a framework for the new disk. Vas-cularization of the graft is probablyderived from the joint periphery.20,21,28,42

The vascular retrodiskal tissue providespluripotential cells and synoviocytes toparticipate in the healing process. Dermalgrafts implanted in the primate TMJ were

Disk

Eminence

Orthopediccrescent knife

FIGURE 50-31 Total diskectomy. A straight clamp isinserted onto the anterior attachment. A meniscus knifeseparates the anterior attachment guided by the clamp.The arrow represents the direction of the incision.

FIGURE 50-32 An arthroscopic knife severs theposterior attachment (broken line), guided bythe clamp. The clamp retracts the disk anterolat-erally for visibility.

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Surgery for Internal Derangements of the Temporomandibular Joint 1007

reported to be viable at postoperative week36.65 The collagen and elastic elements ofthe dermal graft were reported to persist,whereas the dermal appendages atro-phied.66,67 Chao and colleagues reported,however, that the dermal grafts were com-pletely repaired by fibrous tissue.68

The temporalis muscle has been usedas an interpositional material. The flapmay be pedicled in a variety of ways, someof which risk the blood supply owing totorsion of the pedicle. Advantages of thistechnique over a free graft include its sta-bility, owing to its connection at the base(Figure 50-33), its availability at the samesurgical site, and its lack of morbidity.

Feinberg and Larsen described a tech-nique that pedicled the posterior temporalis

muscle fibers anteriorly.69 A 1 cm–widepaddle is developed above the posterior rootof the zygomatic arch. The paddle is elevat-ed and rotated anteriorly and inferiorlyaround the posterior root of the zygomaticarch. The muscle is then sutured to theretrodiskal tissues (Figure 50-34).

Sanders and Buoncristiani describeda technique for using the temporalismyofascial flap for interpositional tissue inTMJ reconstruction.70 The shape and sizeof the flap is outlined by incising posteri-orly near the postglenoid spine of the jointthrough temporalis fascia muscle andperiosteum. This incision is extendedsuperiorly near the temporal line. Subpe-riosteal dissection elevates the amount offlap needed from the temporal bone. Atransverse incision is made at the superiorportion anteriorly to create a 3 cm–wideflap. The width should be greater than theanteroposterior coverage desired in thejoint to allow flap contraction. An anteriorincision is made parallel to the posteriorincision. The superior aspect of the anteri-or incision is carried to bone in this thinarea of the temporalis. Inferiorly, as thearch is approached, the muscle thickens;therefore, the dissections are not carriedcompletely through muscle to bone. Bluntdissection is carried inferiorly to a pointjust medial to the arch to permit adequatemobility of the flap. Branches of the tem-poral artery found in this area are pre-served if possible. The length of the flap isusually 5 cm.

The flap is fully reflected off the bone,and resorbable interrupted sutures areplaced in several areas on the edge of theflap through fascia, muscle, and theperiosteum to keep the layers from sepa-rating. Holes are drilled in the bone of thelateral lip of the glenoid fossa posteriorlyand anteriorly before placement of the flapinto the joint. One suture is placedthrough bone anteriorly near the emi-nence, and a second posterior suture isplaced near the postglenoid spine. Twoadditional sutures hold the medial edge to

anterior and posterior medial tissues.These medial sutures are sometimes diffi-cult or impossible to secure, and thesutures through lateral bone are usuallyadequate to hold the flap in place. A cos-metic temporal defect may result depend-ing on the thickness of tissue harvested.

Autogenous fascia interpositionalgrafts were described in 1911 for use asinterpositional material in gap arthroplas-ties for ankylosis.71,72 The attractiveness ofthis material lies in its resistance to resorp-tion, response to mechanical stress, andbiocompatibility.73–75

Bone

Temporalismuscle

FIGURE 50-33 Disk replacement using tempo-ralis mucle/fascial graft (broken line) pedicledfrom above the glenoid fossa and rotated inward(arrow). Lateral, anterior, and posterior sutureshold the graft in place.

FIGURE 50-34 A and B, Disk replacement usingtemporalis muscle/fascial graft pedicled anteri-orly and rotated anteriorly and inferiorly around(beneath) the posterior root of the zygomaticarch (arrow). The graft is sutured to theretrodiskal tissues.

A

B

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1008 Part 7: Temporomandibular Joint Disease

Autogenous conchal cartilage was firstused as a disk replacement by Perko,according to Witsenburg and Freihofer.76

Cartilage harvested from the cavum con-chae results in minimal esthetic compro-mise. The graft can be tailored to fit thecondyle or glenoid fossa. Notably, thequality and thickness of the aural cartilageis variable. In some cases an iatrogenic tearin the cartilage may occur during the har-vesting process.

The procedure to obtain chondral car-tilage as interpositional material for TMJreconstruction has been described by Halland Link.77 A 3 to 4 cm postauricular inci-sion is made on the ear a few millimeterslateral to the auriculocephalic sulcus and iscarried through to the perichondrium.The middle division of the posterior auric-ular artery may be encountered and ligat-ed or cauterized. A careful supraperichon-dral dissection with a fine dissectingscissors exposes the surface of the carti-lage. A scalpel is used to cut through thecartilage in the shape of the desiredamount of graft, usually 1.5 by 2.5 cm. It isimportant not to extend to the rim of theantihelix to avoid permanent deformity ofthe ear. Subperichondral dissectionbetween the skin of the bowl and cartilagepermits the cartilage to be removed with-out tearing it or perforating the skin. Theear is packed with gauze or other materialto maintain the shape of the bowl and toapply pressure to the skin. The pressurepack is maintained for 48 hours.

Timmel and Grundschober andBoyne and Stringer reported the use oflyophilized dura in both the porcine andhuman TMJ.78,79 Foreign body reactionswere always associated with the material.There was gradual replacement of thematerial with fibrous connective tissue,although they noted this was not completeby 120 to 130 days. There is increasingresistance among surgeons toward usingfresh homologous materials owing to thepossibility of transmitting communicablediseases. Relatively recently Creutzfeldt-

Jakob disease has been transmitted to apatient who received lyophilized dura.80

In the future surgeons may be able touse tissue explants or biocompatible allo-geneic collagen sheets as disk replacements.81

Alloplastic Materials The requirementsfor an ideal alloplastic implant are that it bebiocompatible, easily secured, adaptable tothe variable morphology of the recipientsite, and resistant to the compressive andshear forces of the joint. Currently there isno alloplastic material or technique thatfulfills all of these requirements. Computer-aided design using three-dimensional com-puted tomography images of the TMJ maybring us closer to defining the ideal charac-teristics and design of the various compo-nents of the TMJ.

Silicone elastomer is a rarely usedimplantable material. It is exclusively andrarely used in the TMJ for temporary use,but even in this application it is not free ofproblems. Its sole reputed advantage isthat the material does not incorporate intothe surrounding tissues. In the past whenit was used as a permanent implant, thematerial’s properties were responsible forits migration through stabilizing wires.Gallagher and Wolford suggested that thislack of stability resulted in the loss of asmany as one-third of all implants placedfollowing condylectomy.82 Continuedloading of silicone elastomer interposi-tional implants by the condyle has led tofragmentation and foreign body reactionsbecause of its high coefficient of frictionand poor wear characteristics under directfunction.83 Recognition of the limitationof this material led to the abandonment ofthe permanent silicone implant elastomerand its subsequent rare use as only a tem-porary implant replacement.

Implants laminated with a compositeof polytetrafluoroethylene (PTFE) andaluminum oxide were used extensively inthe early and mid-1980s.84,85 The PTFEmaterial’s ultraporosity and wetabilitypermitted rapid ingrowth of fibrous con-

nective tissue to facilitate anchorage of theprosthesis. The polytef surface on whichthe condyle interfaced was chosen to pro-vide a smooth surface resistant to shearand compressive forces.

In the mid-1980s reports of problemswith the PTFE implant began to surface.84

Patients reported pain, swelling, jointcrepitus, and limitation of range ofmotion resistant to conservative manage-ment. In such TMJ reconstructions thePTFE implants that were removed demon-strated perforations, shredding, and dis-placement. Severe osseous remodelingchanges, particularly of the condyle, werereported.86 Previous reports indicated thatthe PTFE-carbon implants elicited a severehistiocytic foreign body reaction,87 similarto what was being reported as happeningin the human TMJ. Because of the growingnumber of failures with PTFE, in 1990 theFood and Drug Administration formallywithdrew the PTFE implant from the mar-ket and cautioned that patients should beclosely followed up for progressive bonychanges using radiographic studies at 6-month intervals.

Temporary Implant Insertion To dateonly the high-performance polymeric sili-cone implant has been considered for tem-porary (retrievable) implant insertion. Thepaddle-shaped implant is inserted with theneck of the paddle rolled over the zygo-matic arch (Figure 50-35). Several tackingsutures are placed to the temporalis fascia.Retrieval is planned for 2 to 6 months post-operatively. As the polymeric siliconematerial is never incorporated into thehost, the implant is easily removed at a sec-ond operation under local anesthesia. Thefibrous connective tissue that encapsulatesthe implant is left in place to act theoreti-cally as the permanent layer between thecondyle and the fossa. However, at the timeof retrieval of the temporary implant, thefibrous connective tissue encapsulationmay be incomplete. As a result, this proce-dure has dropped out of favor.

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Surgery for Internal Derangements of the Temporomandibular Joint 1009

Condylectomy

Low condylectomy or simply condylectomyis the procedure that is defined as theremoval of the entire condylar process. Theprocedure used to be performed to increasethe joint space to alleviate pressure on nerveendings,48 but it has largely been abandonedin the surgical repertoire for treatment ofinternal derangements because of problemsof reduced condylar mobility, mandibulardeviations, and open bite.

High condylectomy is the removal ofonly the articular surface of the condyle.The disk is left intact to prevent ankylosisand to promote healing. This contrastedwith the radical condylectomy in whichthe tendon of the lateral pterygoid musclewas released. Only slight mandibular devi-ation was reported in patients after highcondylectomy.88–94

When the condylar or eminence artic-ular surfaces appear intact, most cliniciansare reluctant to shave the osseous surfaces.Arthroplasty is performed when the rate

and distribution of bone remodeling haveresulted in mechanical interferences.

Condylotomy

The condylotomy procedure is an osteoto-my performed through the condylar neck.Campbell, one of the originators of thetechnique, made the observation thatsymptoms of TM dysfunction disappearedafter condylar fractures.95 This led to hisapplication of the closed condylotomy topatients with TMJ symptoms refractory tononsurgical therapy. The rationale behindits use in treatment of internal derange-ments was to produce anteromedial dis-placement of the condyle to change thecondyle-disk-fossa relation, increase jointspace, shorten the lateral pterygoid mus-cle, and alter load forces.88,96–100

Originators of the technique per-formed a closed osteotomy with a Gigliwire saw with the intent of creating ananteromedial fracture dislocation. Inter-maxillary fixation was sometimes appliedin the immediate postoperative period.Today, when the procedure is performed,the intraoral route used for the verticalmandibular ramus osteotomy is employed.

Postoperative Management

Surgery should reduce painful symptomsto a level that represents little or no con-cern to the patient. It is important toweigh the contribution of masticatorymuscle myalgia to the patient’s chief com-plaint. Although joint surgery can relievethe joint pain, in many cases it may beineffectual in controlling muscle discom-fort. Nonsurgical management of themuscle disorders must continue in manypatients after surgery for internal derange-ments. Joint surgery does not restore thejoint to its prepathologic state. The patientshould understand that biting force maybe reduced and jaw fatigue may becomeapparent with heavy meals or long conver-sations. After primary surgery (ie, no pre-vious TMJ surgery), one should strive forthe following passive range-of-motion

parameters: maximum interincisal open-ing of 35 to 40 mm, lateral excursivemovements of 4 to 6 mm, and protrusiveexcursive movements of 4 to 6 mm. How-ever, success should not be measured bythe attainment of a finite measurement. Apatient’s overall success should be mea-sured by the eradication or diminution ofthe preoperative complaints. Surgery israrely performed to correct purely func-tional complaints. Elimination of painduring function is usually the predomi-nant concern for the patient, who is will-ing to accept some compromise in degreeof opening and lateral excursions.

Bite appliances should be used tomaintain a stable occlusal relation in theimmediate postoperative phase. This isparticularly important after disk reposi-tioning. The appliance is frequentlyadjusted as the edema resolves and disktissues heal. The patient should be able toreturn to a normal mechanical diet withminimal dietary restrictions. Restrictedfoods include such items as French bread,toffee apples, and popcorn. A stableacceptable occlusion should be main-tained. Joint sounds may develop or per-sist, but the asymptomatic sounds shouldbe of minimal concern to the patient.

Postoperative outcomes may be influ-enced by several factors, including con-comitant facial pain from other sources,degenerative bony changes, advancedmorphologic changes in the disk, perfora-tion of the posterior attachment, poorlycontrolled parafunctional habits, maloc-clusion, psychological overlay, previousTMJ surgery, history of facial nerve paral-ysis or orofacial numbness, history ofinfection, or systemic diseases affecting themuscles, ligaments, or bone.14

Historically, clinicians emphasizedrestricted joint function after jointsurgery. The clinician must balance hisdesire to rapidly and actively restore a nor-mal range of motion with the capacity ofthe joint and facial muscles to adapt. Somelatitude must be maintained on the part of

Implant

FIGURE 50-35 Temporary (retrievable) poly-meric silicone implant inserted. The paddleextension is sutured to the temporalis fascia. AFreer elevator holds the implant in place (arrow)while the sutures are secured.

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1010 Part 7: Temporomandibular Joint Disease

the clinician in dealing with a patient’srehabilitation schedule. Care should beexercised in the rehabilitative process ofthe patient with bilateral joint diseasewhose operation was unilateral. Dietrestrictions are important. Excessive later-al excursive movements to the ipsilateralside may contribute to the exacerbation ofcontralateral symptoms. There is no cook-book recipe to postoperative managementof these patients. Some patients, regardlessof the procedure, achieve an acceptablerange of motion within 7 to 14 days, withminimal effort on their part. Others needto follow a strict physical therapy regimen.The help of a physical therapist may some-times be enlisted to regain joint mobility,especially when patient cooperation with ahome exercise program is questionable. Ingeneral, some light passive opening andprotrusion stretching exercises are pre-scribed four times a day beginning 5 dayspostoperatively. With disk repair proce-dures the physical therapy exercises shouldbe more gradual.

Patients should be maintained on afull-liquid to soft diet for the first 2 post-operative weeks. Heat may be appliedbefore and after exercises to improve com-fort. Splint therapy is routinely used whena large parafunctional component is pre-sent. Some authors advocate using anteri-or repositioning devices to permit healingof suture sites following disk reposition-ing. Patients should be encouraged tochew gum after 4 weeks to improve lateralexcursive movements.

Complications

Complications may arise immediately(intraoperatively or within 24 hr) or bedelayed (> 24 hr).

Transient neuropraxia of the temporalbranches of the facial nerve occurs in asmany as 20 to 30% of cases. Typically, theinjury is of little significance to the patientand resolves within 3 to 6 months. Theincidence increases when a separate skinflap is raised.101 Rarely, the zygomatic

branches and, even more rarely, the entiretemporofacial division may be injured.Injury to the chorda tympani from aggres-sive condylar retraction in the medialaspect of the fossa may occur rarely aswell. Neuropraxia of the inferior alveolarand, less commonly, the lingual nervesmay result from clamp placement for jointmanipulation. Auriculotemporal syn-drome (gustatory sweating, Frey’s syn-drome) has been reported as a result of thedissection of the joint.

Hemorrhage from the retrodiskal tis-sue may interfere with performance of thedisk repair. Temporary control may beobtained with seating of the condyle in theglenoid fossa. Electrocautery, injection ofepinephrine, or application of hemostaticagents while maintaining the mandible inthe closed position may be necessary.

Infections rarely occur. Microorgan-isms cultured may originate from the skinor external auditory meatus flora. Auri-culitis and external otitis are more likely tooccur with the postauricular and endauralapproaches. To avoid contamination anear packing is avoided as it frequentlybecomes dislodged during surgery. Inaddition, the ear is not suctioned duringsurgery. When the wound is closed theexternal auditory canal is irrigated gentlywith saline via an 18-gauge angiocatheter.

Postoperatively, joint sounds are a fre-quent occurrence, regardless of thesurgery. The sounds following diskectomymay be the loudest. In some patients thesounds may be obtrusive enough to dis-turb them. The surgeon should delay re-intervention until the patient is reevaluat-ed at 6 to 12 months, as some sounds maybecome inconsequential to the patient.

Summary

Remarkably good success has been reportedwith several surgical procedures, which dif-fer in their fundamental approach to theproblem and their aggressiveness. Most ofthese techniques share common denomina-tors: first, a lateral approach to the capsule

and ligament; second, a severing of the pos-terior attachment-disk attachments to thecapsule once the superior joint space isaccessed; and, third, a blunt delineation ofthe joint spaces. Although the capsule andligament tissues are approximated at theconclusion of the procedure, the patient isencouraged to function on the operatedjoint. Long before arthroscopic surgery,Toller recognized the importance of mobi-lizing the condyle-disk-fossa relations toachieve a successful result.102 He devised thelateral capsular arrangement procedure. Itremains to be determined whether diskrepositioning, posterior attachment repair,diskectomy, high condylectomy, and evencondylotomy derive some or all of their ther-apeutic benefits through a lateral capsuleand ligament release and mobilization of thedisk complex. Arthrocentesis and arthro-scopic surgical procedures for treatment ofthe closed lock condition appear to be ther-apeutic through the same mechanism.103

Open surgical approaches to TMJinternal derangements are now relegated toa tertiary line of care following nonsurgicaltherapy and arthrocentesis/arthroscopy formost conditions. They do, however, have aclear indication for certain mechanicalconditions directly attributed to a diskobstruction.

Much of what was written in the pre-vious edition of this chapter has stood thetest of time. As we increase our under-standing of the pathology, open surgicalprocedures are being performed for spe-cific well-defined conditions. However, thenew TMJ surgeon will never quite appreci-ate the experience that comes with perfor-mance of arthrotomy procedures.Arthroscopy developed as a consequenceof this experience. Now, as we regress withprogress, arthrocentesis with and withoutsteroid injection, a procedure performedby many surgeons years before the pathol-ogy of the joint was even elucidated, hasbecome a mainstay for treatment. Thistreatment alone has significantly reducedthe need to intervene via arthrotomy.

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