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Arthroscopic diagnosis and surgery of the temporomandibular joint
Abstract
Arthroscopy of the temporomandibular joint (TMJ) has advanced to the point that excellent diagnostic examination and a number of surgical procedures can be performed. A refined technique is presented and instrumentation for surgical arthroscopy is discussed. Short-term results are also presented.
... Arthroscopic surgery of the temporomandibular joint is a complex procedure which requires careful attention to surgical detail. For this reason, we have carefully described the technique in particular defining the anatomy of the joint There have been a number of excellent papers and texts on arthroscopic surgery, and serious students of the techniques are recommended to study them all [1][2][3][4][5][6][7][8][9][10][11][12]. ...
... They described the basic technique and procedure. The papers of Holmlund [7] and Tarro [8] provided different skin markings and entry points to our technique. The main reason for this is they used standardised measurements for all cases, whereas in our technique we individualised the measurements based on the MRI image of each patient. ...
Purpose
This paper describes in detail the first author's technique of performing arthroscopic surgery in both the superior and inferior joint spaces of the temporomandibular joint.
Methods
The key is careful measurement of sagittal and coronal tomograms to determine the individual size and shape of the joint. The joint is then distracted to allow 3-port video arthroscopy.
Results
The detailed steps in the procedure are described and illustrated.
Conclusion
This modified technique is safe and allows procedures in both joint spaces and surgical access to the fossa, condyle and disc.
... However, our findings align with previous reports that the HH plane frequently misaligns with the zygomatic arch, obscuring the accurate placement of the trocar and cannula. [8][9][10] The individualized approach used in this study, which involves detailed measurements from sagittal and coronal CT reconstructions, allows for precise customization of the surgical entry points. This is particularly important in TMJ arthroscopy, where the spatial relationship between the surgical landmarks and the joint can vary considerably between patients. ...
This study introduces a novel technique for arthroscopic surgery of the temporomandibular joint (TMJ), developed by the first author. Traditional TMJ arthroscopy techniques typically utilize a reference plane extending from the lateral canthus to the tragus, which may misalign with the zygomatic arch and create technical challenges during percutaneous joint access. The proposed method addresses these limitations by leveraging coronal and sagittal tomographic measurements alongside 3-dimensional reconstructions to determine precise and anatomically appropriate entry points. The inclusion of a 3-port video arthroscopy system enhances intraoperative visualization and access to the superior joint spaces. Compared with conventional techniques, this refined method demonstrates increased procedural efficiency, improved safety, simplified technical execution, and enhanced reproducibility. Detailed procedural steps are presented, supplemented with illustrative diagrams to ensure clarity and replicability. This innovative approach significantly advances surgical maneuverability, allowing for a comprehensive assessment and treatment of the glenoid fossa, condyle, and articular disc while minimizing the risk of iatrogenic complications often associated with traditional techniques.
... A number of conservative methods are used in the treatment of temporomandibular joint internal derangement, including occlusal splints of various designs, supportive physical therapy procedures, rehabilitation involving muscular training, and specialist psychological support. Surgical treatment can be divided into invasive (open) and minimally invasive (which includes arthrocentesis and arthroscopy) [7]. In internal derangement the protocols for initial treatment consists of choosing reversible and little invasive therapies, such as occlusal splints, non-steroidal anti-inflammatory drugs (NSAID), analgesics, physiotherapy and patient advice. ...
Purpose:
A prospective, randomized study was undertaken to compare arthroscopy and arthrocentesis for treatment of temporomandibular joint disorders.
Patients and methods:
Nineteen patients with clinical and radiographic documentation of internal derangement of the temporomandibular joint(s) unresponsive to nonsurgical therapy were randomized to one of two surgical groups: arthroscopic lysis and lavage under general anesthesia or arthrocentesis, hydraulic distention, and lavage under intravenous sedation. Objective data were collected; including interincisal opening, lateral excursions, occlusal evaluation, deviation on opening, and tenderness to palpation. A questionnaire in the form of visual analog scales relating to pain, joint noise, jaw mobility, and dietary alterations was completed by each patient at 1 week, and 1, 3, 4, 12, and 26 months postoperatively.
Results:
There was no statistically significant difference in outcome between the two groups for any parameter evaluated. Categorization of a particular subject into a successful outcome was based on statistically significant improvement in maximum incisal opening and pain scores; the overall success rate was 82% for arthroscopy and 75% for arthrocentesis.
Conclusions:
Therapeutic success was not significantly different for arthroscopy and arthrocentesis; both surgical modalities are useful for decreasing patient reports of pain while increasing functional mobility of the mandible.
This study evaluated the development and preliminary results of a single-channel thin-fiber and Nd:YAG laser temporomandibular joint arthroscope. No articular damage from the arthroscopic procedure and laser lysis was observed in any of the joints when the arthrotomy was performed. All three disk perforations found by the arthroscope were confirmed at the time of the arthrotomy, and in these joints the tip of the arthroscope could be advanced into the inferior joint. The nine joints, where only arthroscopic laser lysis was performed, were followed up and the results were satisfactory.
Aim:
This study assessed the patients' and clinicians' perception of the outcome of temporomandibular joint arthroscopy.
Method:
All patients who underwent TMJ arthroscopy for both diagnostic and therapeutic purposes over a 6-year period were sent a questionnaire that asked about various symptoms attributable to the TMJ. Additionally a review of the clinical notes was performed.
Results:
83 patients underwent arthroscopy to 127 temporomandibular joints. The mean follow up was 3.6 years. 55% of patients assessed their jaw function as being effective, jaw movement, pain control, and overall satisfaction were satisfactory in 37%, 57%, and 48% of cases respectively. The clinicians' assessment revealed that 45% of patients had no joint tenderness, 74% of patients were able to open to > 35 mm and 74% of patients were free of any joint noise. 66% of patients were prepared to undergo a second procedure if indicated.
Conclusion:
Overall, 50% of patients seemed to view arthroscopy favourably although many patients still felt that jaw opening was restricted. The outcome was not related to the position and reducibility of the disc at surgery and other variables may be responsible. The disparity between the clinical evaluation and the patients' perception of effectiveness emphasises the importance of patient feedback.
Temporomandibular joint (TMJ) arthroscopy was first described by Ohnishi1 in 1975 and since then several authors have described variations of this technique.2–11 Recent clinical applications and modifications of the procedure have produced relatively few documented complications. These complications include anesthetic, neurologic, otologic, hemorrhagic, infections, intra-articular damage to the TMJ, and facial scarring.12–16 The following is a case report describing an acquired arteriovenous fistula (AVF) of the superficial temporal vessels secondary to left TMJ arthroscopy.
The method described in Part I (Price C. A method of quantifying disc movement on magnetic resonance images of the temporomandibular joint. Part I: the method. Dentomaxillofac Radiol 1990; 19: 59-62) is used to compare normal temporomandibular joints with reducing and non-reducing disc displacements. Three examples in each group are illustrated. It appears that the movement in both compartments is similar in normal joints, is decreased in the upper compartment and increased in the lower compartment of those with reducing displacements, and is reduced in both compartments with non-reducing displacements. Displaced discs may obstruct the condylar translation, translation may be reduced without disc contact, or translation may be unimpaired in the presence of severe non-reducing displacement.
This is a prospective study to evaluate therapeutic arthroscopy for internal derangement of the temporomandibular joint (TMJ). Fifty-nine patients with 76 abnormal joints were evaluated preoperatively for pain, noise, maximal incisal opening (MIO), and deviation on opening. Preoperative and postoperative magnetic resonance imaging (MRI) scans were obtained for 29 joints. Patients were treated by superior joint arthroscopy, lysis of adhesions, lavage, and steroid injection, along with preoperative and postoperative splint and physiotherapy. Pain, noise, and motion were evaluated at three time periods: 1) early (10 to 30 days); 2) intermediate (1 to 6 months); and 3) late (greater than 6 months). At early, intermediate, and late follow-up, increase in MIO was statistically significant (P less than .05). Noise did not return in the majority of patients. Disc position, evaluated by MRI, did not appear to change in 25 of 29 joints and did not correlate with clinical outcome. The results of this study indicate that TMJ arthroscopy is effective in reducing pain and increasing motion in patients with TMJ internal derangement.
Dental research continued to grow during 1988. Unfortunately the quality does not always parallel the quantity of publications. This report obviously does not encompass all of the literature but focuses on studies that are related to trends and to matters that are considered controversial. Likewise the particular interests of the members of the American Academy of Restorative Dentistry were taken into consideration. The subjects covered include periodontics, preventive dentistry, bulp biology, craniomandibular disorders, ceramics, color in restorative dentistry, and dental materials.
Temporomandibular joint dysfunction is a complicated problem requiring interdisciplinary cooperation for diagnosis and treatment. Functional problems including bruxism and psychological disorders frequently occur with joint dysfunction making evaluation more difficult. Many new diagnostic modalities are now available to supplement the history and physical examination to provide an accurate assessment of the joint. Although conservative treatment is successful in a majority of the patients, some form of surgical treatment remains the only option for those who do not respond to conservative management. We have discussed the etiology, diagnosis, and treatment of the pathological conditions of the TMJ and introduced a new modality of treatment, temporalis fascia interpositional arthroplasty. Further work is necessary to elucidate the etiology of TMJ dysfunction and develop treatment modalities that avoid the use of alloplastic materials.
The attentive clinician can no longer be satisfied with global diagnostic categories such as "TMJ syndrome" or "MPD syndrome." Nor can one be content with nonspecific diagnostic testing or generic referral. This article has outlined specific components of head and neck pain originating in the masticatory musculoskeletal system. Much progress has been made in recent years, particularly in regard to diagnostic imaging. The future will bring us data on long-term treatment efficacy and a better understanding of chronic pain conditions that lack discrete organic lesions. Finally, the manifestation of psychiatric or psychologic abnormalities as pain is under scientific scrutiny and a better understanding of conversion phenomena will assure proper use of available treatment modalities.
Many patients with temporomandibular joint (TMJ) dysfunction also complain of subjective symptoms of ear dysfunction. This study was undertaken to evaluate preoperatively patients with ear complaints associated with TMJ pain and dysfunction and to examine the effect of essentially uncomplicated TMJ arthroscopy on subsequent ear function. Fourteen patients (22 joints) were examined arthroscopically. The patients were evaluated by an otologist, and hearing tests were obtained pre- and post-operatively. All patients had normal audiometric studies preoperatively, and these remained unchanged postoperatively. It was concluded that uncomplicated arthroscopy of the TMJ does not cause ear dysfunction.
One hundred consecutive surgical arthroscopies of the temporomandibular joint were performed and evaluated with a mean follow-up of 19.4 months. Of the 66 patients, 72.7% had symptoms lasting more than 1 year. The mean postoperative increase in maximal incisal opening was 38.4%. A 7.5% failure rate was noted by objective criteria; 85.7% of the patients rated their postoperative pain and function greatly or moderately improved. All of the respondents stated they would have the arthroscopic surgery again if needed.
A case is reported in which instrument breakage occurred in the temporomandibular joint during arthroscopic surgery. The technique used for removal of the broken metal fragment is described.
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.
A case report of an extradural haematoma (EDH) after temporomandibular joint arthroscopy is presented. The possible cause of this unusual occurrence is discussed.
A prospective, randomized study was undertaken to compare arthroscopy and arthrocentesis for treatment of temporomandibular joint disorders.
Nineteen patients with clinical and radiographic documentation of internal derangement of the temporomandibular joint(s) unresponsive to nonsurgical therapy were randomized to one of two surgical groups: arthroscopic lysis and lavage under general anesthesia or arthrocentesis, hydraulic distention, and lavage under intravenous sedation. Objective data were collected; including interincisal opening, lateral excursions, occlusal evaluation, deviation on opening, and tenderness to palpation. A questionnaire in the form of visual analog scales relating to pain, joint noise, jaw mobility, and dietary alterations was completed by each patient at 1 week, and 1, 3, 4, 12, and 26 months postoperatively.
There was no statistically significant difference in outcome between the two groups for any parameter evaluated. Categorization of a particular subject into a successful outcome was based on statistically significant improvement in maximum incisal opening and pain scores; the overall success rate was 82% for arthroscopy and 75% for arthrocentesis.
Therapeutic success was not significantly different for arthroscopy and arthrocentesis; both surgical modalities are useful for decreasing patient reports of pain while increasing functional mobility of the mandible.
This study was designed to evaluate the efficacy of arthroscopic lysis and lavage for patients with limited mouth opening. The relationship between preoperative mouth opening and the surgical outcome was determined.
Fourteen patients with 16 internally deranged joints were treated by arthroscopic lysis and lavage. All had received 10.4 (7 to 19) months of nonsurgical treatment before arthroscopy. The preoperative magnetic resonance images showed anterior disc displacement without reduction in all treated joints.
Twelve of the 14 patients (86%) showed good reduction in pain and improved range of jaw movement on average follow-up of 28.5 (13 to 66) months. Two patients showed no improvement after arthroscopy and required open surgical procedures. The preoperative mouth opening of the successful group averaged 29.4 (22 to 35) mm, whereas the two failed cases had 10- and 19-mm openings, respectively (P < .05).
Persistent limitation of mouth opening of more than 22 mm after nonsurgical treatment has a good prognosis when treated by arthroscopic lysis and lavage. However, those with greater limitation should probably have earlier surgical intervention.
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.
Twenty-six patients with a sudden-onset of persistent limited mouth opening and with MRI signs of articular discs fixed to the glenoid fossa were studied. After unsuccessful non-surgical treatment, arthroscopy with sodium hyaluronate infusion was performed in 16 joints. Follow-up ranged from 24 to 60 months (mean: 30.3 months). All patients were clinically assessed preoperatively, and at 1, 3, 6, 9, 12, 18 and 24 months postoperatively. The clinical variables analysed were: joint pain using a visual analogue scale (VAS) (1-15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). MRI images were obtained preoperatively to analyse the morphological and dynamic characteristics of the temporomandibular joint. Eight of the patients who refused to undergo arthroscopy were treated with arthrocentesis. These patients were studied following the same criteria as stated above. Mean age of the group was 24.3 years (16-35 years). 20 patients were female and 6 male. The preop-MRI examination revealed a normal disc position in 16 joints and an anteriorly displaced disc in 10 cases. All of the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. After non-surgical treatment only two patients improved while all the other patients showed a severe decrease in the MIO (mean 23.3 +/- 2.2 mm), LM (3.8 +/- 1.4) and a high pain level (9.7 scale). Sixteen patients underwent arthroscopy. A significant reduction in pain was noted after arthroscopy. Furthermore, a significant increase in MMO and LM was demonstrated postoperatively. Arthroscopic findings included the presence of adherences and synovitis. Eight patients who refused arthroscopy were treated with TMJ arthrocentesis. All such patients improved their symptoms postoperatively. In conclusion both TMJ arthroscopy and arthrocentesis give good results upon treating patients with anchored disc phenomenon (ADP).
The surgical technique for arthroscopic examination of the superior space of the temporomandibular joint and the morbidity encountered with the procedure in 50 cases are presented. Eighty-eight per cent of the examinations provided diagnostic information. There were no serious complications, and minor short-term complaints were encountered in only 12% of the examinations.
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.
Arthroscopy of the temporomandibular joint (TMJ) is evaluated on an autopsy material. 2 different types of arthroscope--one with a rod-lens system and one with a so-called Selfoc system--were used and compared regarding diagnostic accuracy. On 54 cadavers, it was found that the upper joint compartment may be punctured with accuracy and without damage to vital tissues. Landmarks on the skin facilitating clinical arthroscopy were defined in relation to a guideline from tragus to lateral canthus. A further 49 TMJ specimens were investigated with arthroscopy. The findings are in good agreement with subsequent observations made during dissection. Regarding arthrotic changes, 100% diagnostic accuracy was achieved with both types of arthroscope. Regarding remodelling changes, the diagnostic accuracy was approximately 57%. No significant difference was noticed between the 2 arthroscopes. Photographic documentation with the rod-lens arthroscope was found to be of superior quality.
2 patients with a history of reciprocal temporomandibular joint (TMJ) clicking were visually examined with arthroscopy of their right side TMJs. Clinical and radiographic examination revealed no signs of arthrosis deformans. One patient with significantly reduced opening ability combined with occasional disappearance of TMJ clicks showed advanced arthrotic changes of cartilage which were not visible radiographically. The other patient with unimpaired function also had a severe arthrotic lesion in the clicking joint. In neither case did the disk appear to be displaced. It is concluded that arthroscopy yields additional information for TMJ diagnosis which cannot be achieved by clinical and radiographic examination alone.
Complications of arthroscopic surgery (lecture given at Symposium on TMJ Arthroscopy and Arthro-scopic Surgery). Long Beach. CA
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Arthroscopy of the temporomandibular joint—An autopsy study.
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Arthroscopy of the temporomandibular joint—Examination of 2 patients with suspected disc derangement
- Hellsing
Suppurative arthritis of the temporomandibular joint. A report of a case with special reference to arthroscopic observations
- Murataine