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A fully visualized arthroscopic disc suturing technique
Abstract
Advanced arthroscopic procedures, including disc suturing, are advantageous in managing temporomandibular joint disorders. These techniques are indicated in cases of long-standing closed lock, displaced discs with reduction, and hypermobility with chronic dislocation. Disc suturing procedures can be done blindly, partially blindly, or fully visualized. Fully visualized suturing techniques have obvious advantages, but can be time-consuming, difficult to perform, and traumatic. This article presents a new suturing technique that is fully visualized and is less time-consuming and relatively easy to perform.
... First reported in English byIsrael in 1989 [74], important variations soon followed[75][76][77][78][79]. The technique documented in 1992 by McCain et al.[80], involving 11 temporomandibular joints (8 patients), was subsequently modified by Yang et al. in 2012[81]. ...
Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.
... One of the most notable developments in advanced TMJ arthroscopy in the last 10-15 years has been the development of discopexy for repositioning and fixation of an anteriorly displaced TMJ disc [72,73]. First reported by Israel in 1989 [74], important variations soon followed [75][76][77][78][79]. The technique documented in 1992 by McCain et al [80] involving 11 temporomandibular joints (8 patients was subsequently modified by Yang et al in 2012 [81]. ...
Temporomandibular disorders (TMD) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant case. Several recent advancements in the TMD and temporomanidbular joint (TMJ) surgery have elevated understanding and ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements of TMJ disorders and their surgical management.
... In 1989, Israel, 8 Tarro, 9 and Ohnishi 10 independently first described the use of arthro- scopic suture for the treatment of anterior disk displacement or recurrent mandibular disloca- tion. Posteriorly, several techniques for arthro- scopic suture were described by McCain and colleagues 11 in 1992, Tarro 12 in 1994, and Goizueta-Adame and Mu? oz-Guerra 13 and Yang and colleagues 14 in 2012. Description of each of these techniques and discussion of their advan- tages and disadvantages are beyond the scope of this article. ...
Several open surgeries have been proposed for the treatment of internal derangement (ID) of the temporomandibular joint (TMJ), although minimally invasive temporomandibular joint surgery (MITMJS) plays a major role in the treatment of ID and has been widely used for the treatment of ID of the TMJ. Arthrocentesis, arthroscopic lysis and lavage, and operative or advanced arthroscopy are the 3 most relevant techniques for MITMJS; clear indications for their application and a detailed description of each technique are presented. Also, clinical outcomes for each technique from the most relevant studies in the literature are reported.
Copyright © 2015 Elsevier Inc. All rights reserved.
This chapter details arthroscopic arthroplasty of the temporomandibular joint (TMJ). It is a minimally invasive procedure used to diagnose and/or treat numerous joint pathologies. The chapter focuses on surgical indications, contraindications, pertinent anatomy, virtual surgical planning, operative techniques, postoperative management, complications and key points of arthroscopic arthroplasty of the TMJ. The TMJ is a diarthrodial joint separated into inferior and superior compartments by the articular disc. The inferior joint space is responsible for hinge opening or rotation, and the superior joint space is responsible for gliding or translation motion, which is the second phase of opening. The chapter also provides several case reports with high‐quality images.
Aim
The aim of the present study is to assess the outcomes of monoportal arthroscopic disc repositioning (discopexy) for disc displacement of the temporomandibular joint.
Material and methods
A retrospective, single-institutional clinical study included patients with temporomandibular joint internal derangements diagnosed and treated by monoportal discopexy. Each patient was diagnosed as having anterior disk displacement with or without reduction. The arthroscopy treatment consists of one portal approach fixing the disc with a 3/0 nylon to the tragus cartilage without anterior liberation. Arthroscopy surgery was carried out with a 1.9-mm 0º arthroscope and only one simple cannula. We use a needle to pierce of the disc through the skin and retrieve the suture inside the joint using a blind method through the arthroscopic cannula. The evaluated variables included the maximum interincisal opening, the presence of clicking and pain score.
Results
A total of 19 patients, 21 joints, were included in the present study. Of the 21 joints, 16 were classified as disc displacement with reduction and 5 without. Visual analogue scale (VAS) values (0-10) decreased from 5.5 to 1.26 (p < 0.0001) 1 year after surgery. At the first review, all patients had a VAS of at least 4 points less than before the surgery, four patients showed a VAS of 0, and nine patients near to 1. Mouth opening increased from 36.6 (±8.09) mm to 39.37 (±4.35) mm, and no significant limitations in the mouth opening range were seen (p < 0.12) 1 year after surgery. Clicking disappeared in all patients and remained stable after 12 months of follow-up. Postoperative magnetic resonance imaging demonstrated a correct or improved position of the disc in all but one patient.
Conclusions
A minimally invasive single portal arthroscopic discopexy is an effective technique to improve function and pain reduction in patients with anterior disk displacement with or without reduction.
Arthroscopic arthroplasty is a minimally invasive procedure used to diagnose and/or treat numerous joint pathologies. The most influential muscle involved in temporomandibular joint (TMJ) function is the lateral pterygoid muscle due to its attachment to both the disk and the condyle. The patient is placed supine on the operating room table and nasally intubated. Standard landmarks are marked and include a line drawn from the lateral canthus of the eye and the tip of the tragus. A Mayo needle is used to thread the suture from anterior to posterior. In order for the knot to be buried in the subcutaneous fatty tissue, a straight hemostat is used to dissect down the suture tracing anteriorly to the capsule through the slit incisions. Postoperative management involves, among other things, ice packs being placed continuously within the TMJ region.
Mandibular dislocation involves dislocation of condyle of mandible from glenoid fossa of temporal bone. Long standing Temporomandibular joint dislocation is a clinical entity which often goes undiagnosed. When diagnosed, commonly, surgical intervention becomes necessary for its correction. This article presents one such case, its diagnosis and management. We describe an innovative technique using a Fergussen's mouth gag as an aide to manual reduction in long standing cases which may usually be difficult or impossible to manage without surgery.
Oral and maxillofacial surgery is entering a new era. Surgeons can use the latest technological advances in equipment in an attempt to improve patient outcomes. Minimally invasive surgery with the use of the endoscope has improved in recent years because of technological advancements in optics and associated instrumentation. Trauma, orthognathic, sialoendoscopy, and temporomandibular joint surgery are commonly performed with the assistance of the endoscope. From an educational standpoint, surgical anatomy and various other principles can easily be taught to trainees with the assistance of the endoscope. The operating surgeon can visualize an area via the endoscope, and instruct regarding the surgical maneuvers on the monitor, without obstructions to view. This technique also allows others in and out of the room to view the image. Endoscopically assisted surgery is gaining popularity and is becoming a tool frequently used by surgeons to assist in and simplify some of the more difficult techniques that often require more extensive surgical exposure for visualization.
In 1993 and 1994, 720 patients with pain in the temporo-mandibular joint area were examined and treated. The authors describe their therapeutic protocol. Sixty-two patients were not relieved by conservative nonsurgical therapy and were treated by arthroscopy or arthrocentesis. In both groups the differences in functional result and in pain control were analysed. Results show that both arthroscopy and lavage are useful in improving function and diminishing pain. Arthroscopy shows better results for functional treatment whereas arthrocentesis and arthroscopy show similar results in pain control.
Recent advances in ultrasound imaging suggested endoarticular ultrasound imaging of the temporomandibular joint (TMJ) in combination with TMJ-arthroscopy as a new diagnostic method. Our investigations were performed on human cadavers, in combination with traditional TMJ-arthroscopy. During our investigations, the main articular structures were identified: the glenoid fossa of the temporal bone, articular disc, condyle of the mandible, and retrodiscal tissue. The combination of arthroscopy and ultrasound imaging provides more information on position, movement, and pathological changes in joint structures. Although all of the advantages, disadvantages, indications, and complications of this new diagnostic procedure are not yet clear, the authors consider this new method a useful diagnostic procedure for TMJ imaging.
Eight patients (11 joints) underwent arthroscopic disc repositioning and suturing. Disc displacement was established by physical examination, magnetic resonance imaging (MR), and diagnostic arthroscopy. Postoperative MRIs were taken at varying intervals between 1 day and 6 months. In all 11 joints, either partial improvement or normal disc position was observed arthroscopically. In 9 of the 11 joints, either partial improvement or normal position was observed on the postoperative MRIs. It is concluded that posterior disc repositioning and suturing is an achievable goal of temporomandibular joint arthroscopy.
Arthroscopic surgery of the temporomandibular joint has been routinely performed by a relatively small number of surgeons for about three to four years. With advances in instrumentation, techniques, and education, it is anticipated that many more surgeons will be performing temporomandibular joint arthroscopic diagnosis and surgery in the near future. The purpose of this paper is to discuss the rationale of temporomandibular joint arthroscopic techniques and the results of arthroscopic surgery involving 152 temporomandibular joints with observation periods ranging from two to 31 months.
Arthroscopic surgery was applied to correct various disorders of the temporomandibular joint (TMJ). Lysis and lavage of the upper TMJ compartment proved of value in patients with anterior disc displacement without reduction ("closed lock"), because it increased the range of mouth motion and alleviated pain in the TMJ. Because this beneficial arthroscopic intervention did not encompass repositioning the disc, its surgical relocation when attempting to overcome dysfunction and pain in the TMJ is questioned.
Nineteen subjects with documented intra-articular pathology refractory to nonsurgical therapies underwent temporomandibular joint (TMJ) arthroscopy involving lysis and lavage in the superior joint space. Following surgery, subjects were evaluated for 6 to 12 months by clinical examinations and questionnaires at designated time periods and by postsurgical joint imaging. Significant improvement was noted in pain, mandibular movement, and diet. No improvement was noted in the incidence of joint sounds, and disc position was unchanged in 80% of the joints. The findings suggest that disc repositioning may not be needed to achieve clinical success.
The effect of arthroscopic release of temporomandibular joint (TMJ) discs was prospectively studied using a combination of preoperative tomograms, magnetic resonance imaging (MRI) scans and arthrograms, and postoperative MRI scans. Of 92 patients studied, 60 had bilateral and 32 had unilateral joint disease. All of the 152 joints studied had anterior disc displacement preoperatively. Postoperative MRI scans revealed that 92% of the patients had persistent anterior disc displacement, although 80% of the patients did have marked improvement of disc mobility. Ninety-two percent of the total patient sample had a significant reduction in pain and restoration of normal mandibular function.
Two hundred thirty-seven patients (419 temporomandibular joints) who had undergone arthroscopic surgery were retrospectively studied with a mean follow-up of 10.5 months (range 1 to 33 months). These results confirmed those of previous short-term studies on successful arthroscopic surgery.
A new suturing technique for stabilizing anteriorly displaced discs that have been reduced arthroscopically after removal of adhesions, lateral pterygoid release, and stretching the lateral capsule is presented. This procedure has provided successful results, although the evaluation is only short-term. No complications have occurred using this suturing technique.
In 20 temporomandibular joints (TMJs) (15 patients) with internal derangement associated with severe pain, the presurgical radiographic findings were compared with the morphologic and histologic alterations. Disc extirpation was performed in 17 joints, and in three joints the disc was surgically repositioned. Deformation of the disc observed by double-contrast arthrotomography was verified histologically. Perforation of the posterior disc attachment was seen in two joints; both were associated with osteophyte formation and flattening of the articular eminence. The white disc-like structure in 11 cases was composed of an anterior, stiff, bulgy, biconvex structure combined with a posterior flattened portion that grossly was incorrectly determined to be part of the disc, but that was identified histologically as a posterior disc attachment that had undergone adaptive change characterized by connective tissue hyalinization. In the arthrotomogram the disc position could easily be determined. However, the disc-like clinical appearance of the posterior disc attachment in these cases made determination of disc position at surgery uncertain or impossible. The nonhyalinized posterior disc attachment was intensely red and showed advanced histologic alterations of the vessels, deposits of extravasated erythrocytes and fibrin, and altered composition of the connective tissue. Thus, signs of inflammation were present but without activation of the local immune system since no major inflammatory cell infiltrates were seen. Small accumulations of lymphocytes were seen in only two cases. The surgically extirpated posterior attachments were innervated by silver-positive nerve fibers ranging in diameter from 1 to 15 micron. The severe pain in the TMJs is likely to have originated from this innervated posterior disc attachment or capsule and to have been triggered by the vascular reaction.
Arthroscopic surgery to correct symptoms of persistent closed locking of the temporomandibular joint appears, in the short term, to be an alternative to arthrotomy. Obviously, long-term follow-up will be necessary.
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