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Advancements in Temporomandibular Joint
Arthroscopy: Refinements in Surgical Techniques
for Treating the Superior Joint Spaces
Alvaro Andres Rodríguez Saenz, DDS,*Brandon Galviz Tabares, DDS,*
Juan Pablo Gnecco, DDS,*Carlos Eduardo Borda López, DDS,*
Nicolás Delgado Burbano, DDS,*and Diego Rodríguez-Sáenz, MD
†
Abstract: This study introduces a novel technique for arthro-
scopic 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 lev-
eraging coronal and sagittal tomographic measurements along-
side 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 conven-
tional techniques, this refined method demonstrates increased
procedural efficiency, improved safety, simplified technical ex-
ecution, 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 ar-
ticular disc while minimizing the risk of iatrogenic complications
often associated with traditional techniques.
Key Words: Arthroscopy, glenoid fossa, mandibular condyle,
temporomandibular joint
(J Craniofac Surg ;00: 000–000)
The temporomandibular joint (TMJ) is essential for the bio-
mechanics of mastication and jaw movement, serving as a
critical component of the craniofacial system. Arthroscopic
surgery has emerged as a valuable intervention for managing
TMJ disorders, offering minimally invasive treatment options
with superior visualization and reduced morbidity compared
with open surgical techniques. Early pioneers, such as Holm-
lund and Hellsing, introduced the anatomic reference plane
between the lateral canthus and the tragus, which remains
widely used for arthrocentesis procedures.1This approach,
however, being a blind technique, depends heavily on the ac-
curacy of the Holmlund-Hellsing line (HH line) for joint space
identification.2Despite its utility, several studies have noted
difficulties in needle insertion when this method is employed,3
underscoring the need for innovative techniques.
Arthroscopic examination of the TMJ, initially described by
Ohnishi,4began as a diagnostic tool for joint pathologies. Over
time, this technique expanded to encompass surgical inter-
ventions within the superior joint space, enhancing its surgical
applications.5Conventional arthroscopic approaches, including
those using the HH line, are sometimes limited by misalignment
with the zygomatic arch, which can present technical challenges
during percutaneous joint access.6Arthroscopic methods have
advanced to include a range of procedures, such as synovec-
tomy, disc repositioning, exploration of the lower joint com-
partment, and osteoplasty for managing chondromalacia and
osteoarthritis.7Despite these advances, the demand for im-
proved techniques that enhance access, precision, and overall
outcomes persists.
This study introduces a novel technique developed by the
first author, which modifies traditional arthroscopic approaches
by employing 3 entry ports for comprehensive access to the
TMJ. This approach incorporates precise sagittal tomographic
measurements to evaluate joint morphology, enabling accurate
placement of entry ports. The enhanced surgical access provided
by this method results in improved maneuverability, superior
visualization, and greater precision. This modified approach
demonstrates significant advantages over classic entry tech-
niques, including increased procedural efficiency, improved
safety, and greater reproducibility.
PATIENTS AND METHOD
A retrospective analysis was conducted on patients assessed,
diagnosed, and treated at the Maxillofacial Surgery Depart-
ment of University Hospital “Los Cobos Medical Center”
by Dr Alvaro Andres Rodríguez Saenz, an Oral and
Maxillofacial Surgeon from El Bosque University in Bogotá,
Colombia. Between January 2022 and November 2024, 81
patients (162 bilateral TMJ arthroscopies) with tempor-
omandibular joint disorders were treated. The patient cohort
rangedinagefrom20to60andcomprised10maleand71
female participants.
From the *Department of Oral and Maxillofacial Surgery, Universidad
El Bosque and Los Cobos Medical Center, Bogota, Colombia; and
†University of Tolima School of Medicine, Ibagué, Colombia.
Received November 22, 2024.
Accepted for publication November 26, 2024.
Address correspondence and reprint requests to Brandon Galviz Tabares,
DDS, Universidad El Bosque and Los Cobos Medical Center, Ak. 9
#131a-2, Bogotá 110231, Colombia. E-mail: bgalviz@unbosque.edu.co
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL
citations are provided in the HTML and PDF versions of this article
on the journal’s website, http://www.jcraniofacialsurgery.com.
Copyright © 2024 by Mutaz B. Habal, MD
ISSN: 1536-3732
DOI: 10.1097/SCS.0000000000011015
ORIGINAL STUDY-TECHNICAL STRATEGIES
The Journal of Craniofacial Surgery Volume 00, Number 00, ’’ 1
Copyright © 2024 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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All patients underwent arthroscopic surgery for TMJ access,
performed by the same surgical team to ensure consistency in
technique and outcomes. Data collected included patient dem-
ographics (age and sex), anatomic measurements at the glenoid
fossa, operative time for TMJ access, and specific tempor-
omandibular disorder diagnoses. This data was recorded in an
Excel spreadsheet and analyzed using descriptive statistics with
IBM SPSS Statistics software.
Ethical approval for this study was obtained from the Fac-
ulty Ethics Committee, and all procedures complied with the
current version of the Declaration of Helsinki. Written in-
formed consent was secured from all patients for the publication
of data and images.
Preoperative
Each patient underwent a comprehensive preoperative as-
sessment, which included a detailed review of medical history,
evaluation of prior conservative treatment responses, physical
therapy assessment, and psychological evaluation. Inclusion
criteria for this study included patients diagnosed with intra-
articular temporomandibular joint pathology, presenting with
clinical symptoms such as joint pain, preauricular pain, and
reduced quality of life. These clinical findings were corroborated
by advanced imaging techniques, including computed tomog-
raphy (CT) and magnetic resonance imaging (MRI) of
the TMJ.
Computed tomography (CT) scans were particularly critical
in measuring the anatomic dimensions of each patient’s TMJs in
both the sagittal and coronal planes. These precise measure-
ments were essential for determining the optimal insertion
points and depths for surgical cannulas and instruments, facil-
itating accurate and efficient surgical access to the superior
joint space.
CT Scan
Coronal Plane Measurements of the Glenoid Fossa
Coronal plane CT measurements of the glenoid fossa were
performed on the cohort of 81 patients in conjunction with
arthroscopic findings. These measurements were derived from
tomographic sections in the coronal plane, focusing on depth
assessments of the glenoid cavity. The following 3 distinct
measurements were recorded, as summarized in Supplemental
Table 4, Supplemental Digital Content 1, http://links.lww.com/
SCS/H228:
1. First measurement: the depth was measured from the
anterior auricular notch to the posterior edge of the glenoid
cavity, on a plane extending 1 cm anteriorly from a line
connecting the anterior auricular notch and the base of the
nasal ala. The average recorded depth was 27.8 mm.
2. Second measurement: this measurement was taken from a
plane located 3 cm anterior to the anterior auricular notch
to the anterior edge of the glenoid fossa. The average depth
measured was 31.27 mm.
3. Third measurement: the depth was assessed from the
intertragic fissure to the posterior edge of the mandibular
ramus, with an average depth recorded at 33.63 mm.
These coronal plane measurements provide insights into the
anatomic spatial dimensions of the glenoid fossa, facilitating the
refinement of entry points and enhancing the precision of the
surgical approach. The individualized anatomic assessments
emphasized the importance of accurate, patient-specific meas-
urements in optimizing surgical outcomes and minimizing
complications (Supplemental Table 4, Supplemental Digital
Content 1, http://links.lww.com/SCS/H228).
Description of the Reference Plane and the
Points of Insertion
To achieve precise and safe arthroscopic access to the tem-
poromandibular joint, a technique utilizing anatomically de-
fined entry points based on specific reference structures on the
patient’s face is proposed. This method ensures effective and
controlled access to the TMJ through a 2×2 cm equilateral
triangle created over the joint, determined using computed to-
mographic measurements.
Point Descriptions and Anatomic Landmarks:
1. Point A (initial entry point): positioned 10 mm anterior to
the anterior notch of the auricle, on a plane defined by the
anterior notch and the nasal ala. This point, located at the
posterior edge of the glenoid fossa, provides access to the
superior joint space of the TMJ. Its strategic placement
minimizes the risk of injury to the facial nerve and the
external auditory canal. The average distance of the
posterior edge of the glenoid fossa over the plane was
measured at 9.72 mm on the right side and 9.10 mm on the
left side, standardized to ∼10 mm bilaterally for ease of
reference.
2. Point a’(return port for lysis and lavage): situated 20 mm
anterior to the anterior notch of the auricle on the plane
defined by the anterior notch of the auricle and the nasal
ala. This port serves as the entry for fluid management
within the TMJ, facilitating lysis and lavage procedures.
3. Point B (operative port): located 30 mm anterior to the
anterior notch of the auricle on the same reference plane.
This point is essential for performing more invasive joint
space interventions, such as coagulation, retrodiscal scar-
ification, intra-articular medication administration, and
biopsies. The average distance to the anterior edge of the
glenoid fossa at this location was recorded as 28.6 mm on
the right and 27.8 mm on the left, standardized to ∼30 mm
for both sides.
4. Point C (port for articular disc fixation): placed 10 mm
anterior to the intertragic notch, aligning with the posterior
border of the mandibular ramus when the mouth is open.
This port is used for procedures that involve securing the
articular disc to the mandibular condyle with absorbable or
titanium screws. The average distance to the posterior edge
of the mandibular ramus was 11.8 mm on the right side and
11.2 mm on the left, standardized to 10 mm for consistency.
5. Point b’(central point of the equilateral triangle): located
centrally within the triangle formed over the glenoid fossa
and coinciding with the mandibular condyle during mouth
opening. This point allows for semi-rigid meniscopexy,
facilitating lower discal access and effective disc manipu-
lation.
Technical Advantages and Imaging Evidence:
The proposed 2×2 cm reference plane, parallel to the zy-
gomatic arch, enhances the precision of cannula insertion for
level III TMJ arthroscopy. This approach supports procedures
such as adhesion removal, osteoplasty, radiofrequency treat-
ment, and meniscopexy. Comparative analysis of the traditional
Holmlund-Hellsing (HH) plane and the 2×2 technique dem-
onstrates superior accuracy with the latter for cannula insertion.
Key measurement points and procedural illustrations are de-
picted in Figures 1–5.
Rodríguez et al The Journal of Craniofacial Surgery Volume 00, Number 00, ’’
2Copyright © 2024 by Mutaz B. Habal, MD
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Operative Preparation
All arthroscopic procedures are conducted under general
anesthesia with nasotracheal intubation to ensure optimal air-
way control. The patient’s head is positioned laterally to pro-
vide clear access to the preauricular region. Hair in the
preauricular area is adequately covered, and sterile drapes are
applied around the site, taking care not to obscure the face or
mouth, which is necessary for jaw manipulation during surgery.
Skin markings are made with surgical markers according to the
guidelines depicted in Figure 1.
Operative Technique
A 2 mL intra-articular injection of bupivacaine is ad-
ministered into the posterior compartment of the superior joint
space to achieve several objectives: distension of the joint space,
local anesthesia, and vasoconstriction of the bilaminar zone.
This injection is made at Point A (refer to Fig. 1), 10 mm
anterior to the anterior auricular notch, on the plane between
the notch and the nasal ala, positioned just below the glenoid
fossa rim.
Cannula Insertion and Arthroscopic Access:
1. The sharp cannula and trocar are introduced at Point A
with a 45-degree upward, forward, and medial angle. The
trocar traverses through the periosteum of the zygomatic
arch, advancing into the superior joint space within the
glenoid fossa. Once the periosteum is penetrated, the sharp
trocar is withdrawn, and a 2.7 mm, 30-degree rod lens video
arthroscope is inserted into the cannula for a thorough
examination of the superior joint space.
2. A secondary portal, Point a’, is established 10 mm anterior
to Point A and acts as an outlet for the lysis and lavage of
intra-articular fluids.
3. Point B, located 30 mm anterior to the anterior auricular
notch, aligns with the anterior section of the TMJ. This
access point supports the use of a probe for disc
manipulation and facilitates the insertion of a third cannula.
4. Point C, positioned 10 mm anterior to the intertragic notch,
aligns with the posterior border of the mandibular ramus
during mouth opening. This portal allows for rigid
meniscopexy, where resorbable or titanium screws are
employed to secure the articular disc.
5. Point b’, the center of the equilateral triangle formed over
the glenoid fossa, aligns with the mandibular condyle when
the mouth is open, serving as an access point for semi-rigid
meniscopexy and lower discal manipulation.
These carefully delineated entry points, aligned with ana-
tomic landmarks, enhance surgical precision, minimize the risk
of facial nerve damage, and allow for efficient performance of
TMJ arthroscopic procedures, such as adhesion removal, disc
repositioning, and intra-articular injections.
FIGURE 1. (A) Diagrammatic representation of skin measurement over the
reference plane created from the anterior auricular notch and the nose ala. (B)
3D reconstruction with reference plane between the anterior notch of the
auricle and the nasal ala. (C) The 2×2 cm equilateral triangle formed using the
reference plane with entry points marked on the skin in the preauricular region:
point A: 10 mm anterior to the anterior notch of the auricle, at the posterior
edge of the glenoid fossa (∼10 mm). Point a’: 20 mm anterior to the anterior
notch of the auricle. Point B: 30 mm anterior to the anterior notch of the
auricle, at the anterior edge of the glenoid fossa (∼30 mm). Point C: 10 mm
anterior to the intertragic notch, aligning with the posterior border of the
mandibular ramus (∼10 mm). Point b’: center of the equilateral triangle over
the glenoid fossa, aligned with the mandibular condyle.
FIGURE 2. Arthroscopy images of level 3 TMJ surgery procedures. (A)
Application of radiofrequency to the retrodiscal tissue for coagulation and
scarification. (B) Arthroscopic meniscopexy was performed for disc
repositioning and stabilization. (C) Arthroscopic forceps grasping the intra-
articular suture for meniscopexy.
FIGURE 3. CT-3D Reconstruction for cannula insertion depth assessment. (A)
The CT-3D reconstruction without the mandible illustrates the depth from the
soft tissue surface to the center of the glenoid cavity. (B) The axial CT-3D
reconstruction with the mandible and soft tissue shadow demonstrates the
same depth measurement. These reconstructions were used to gather precise
depth data in 81 patients, aiding in the standardization of cannula insertion
during TMJ arthroscopy. By accurately assessing these depths, surgeons can
minimize the risks of over-penetration and avoid damage to critical structures
such as the ear canal. Establishing these averages helps ensure safer and more
effective surgical outcomes.
FIGURE 4. Comparative analysis of “HH”and 2×2 reference planes for TMJ
access. (A) Lateral view displaying the 2x2 technique, which employs an
equilateral triangle to establish entry points for arthroscopy. Unlike the ‘HH’
plane, the 2x2 reference plane aligns parallel to the zygomatic arch, ensuring a
more consistent anatomical orientation. (B) Lateral view illustrating the
traditional Holmlund-Hellsing (‘HH’) reference plane, commonly used in TMJ
surgeries.
The Journal of Craniofacial Surgery Volume 00, Number 00, ’’ Advances in TMJ Arthroscopy Technique
Copyright © 2024 by Mutaz B. Habal, MD 3
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Postoperative
After general anesthesia and removing the nasal-tracheal
tube, ice packs are applied with gentle pressure. Standard
postoperative monitoring is conducted for several hours as
needed. Patients who are in good health and undergo surgery in
the morning are typically discharged 4 to 6 hours after the
procedure. However, patients who are medically unfit, undergo
extensive procedures or lack adequate postoperative care at
home are admitted for overnight observation.
RESULTS
1. Procedure duration and comparative analysis. The mean
duration of arthroscopic procedures was determined for both
level II and level III interventions. Level III procedures
averaged 15 minutes, whereas level II procedures were
completed in an average of 6 minutes. A direct comparison
between the 2×2 technique and the traditional Holmlund-
Hellsing approach revealed significant differences. The right
side, treated using the 2×2 technique for semirigid menisco-
pexy, had an average operative time of 6 minutes, compared
with 11 minutes on the left side using the Holmlund-Hellsing
technique. The latter method encountered complications such
as temporal artery hemorrhage and limited working space
between entry ports, contributing to longer surgical times.
2. Patient demographics and case distribution. The study
included 81 patients (71 females and 10 males), with an age
range of 20 to 60 years. The majority, 28.4%, were within
the 50 to 59 age group (refer to Supplemental Table 1,
Supplemental Digital Content 1, http://links.lww.com/SCS/
H228 for a detailed age distribution).
3. Classification of TMJ disorders. The severity and classi-
fication of temporomandibular joint disorders were assessed
using the Wilkes Classification:
60.4% were categorized as Wilkes III (moderate to
severe dysfunction with disc displacement without
reduction).
25.9% were Wilkes II (less severe conditions with disc
displacement with reduction).
12.9% were Wilkes IV, indicative of degenerative joint
changes.
4. In addition, the Bronstein Classification showed:
40.7% of cases were Bronstein II, indicating synovitis
and 50% roofing.
50% were Bronstein III, reflecting more pronounced
synovitis and chondromalacia, with 25% roofing
present (see Supplemental Table 3, Supplemental
Digital Content 1, http://links.lww.com/SCS/H228
for further details).
5. Statistical analysis. Descriptive statistics and cross-tabula-
tions were carried out using IBM SPSS Statistics to
analyze data.
Complications
Complications can be minimized through meticulous atten-
tion to surgical technique. It is crucial to avoid penetrating
deeper than the measured distance from the skin to the medial
condyle in the coronal plane. When inserting the sharp trocar at
point A, it must be directed medially and anteriorly, avoiding a
posterior direction to prevent potential damage to the middle
ear structures. The most frequent complication encountered is
neuropraxia of the frontal branch of the facial nerve, which
typically resolves within 3 months. However, there remains a
risk of more severe nerve injury from the sharp trocar at point
A. Although these more severe injuries could be permanent,
none have been observed in the author’s experience with this
technique. Thorough preoperative counseling is imperative, as
patients must be informed of these potential risks to ensure valid
informed consent.
DISCUSSION
Arthroscopic surgery of the TMJ is a precise and technically
demanding procedure that requires a thorough understanding
of joint anatomy and surgical techniques. In this study, we in-
troduce a modified technique that employs individualized
measurements to optimize trocar placement and access to the
superior joint space. This approach addresses limitations in
previous methods, offering enhanced precision and improved
patient outcomes.
Historically, pioneers like Ohnishi4and Rosenberg and
Goss7with Bosanquet established the diagnostic and ther-
apeutic foundations of TMJ arthroscopy, focusing on exploring
and managing the superior joint space with diagnostic arthro-
scopy, setting the stage for further innovations, such as in-
tegrating therapeutic interventions like synovectomy, disc
repositioning, and osteoplasty within the arthroscopic field.
Traditional techniques, such as the Holmlund-Hellsing (HH)
line, have aimed to standardize needle placement in blind pro-
cedures like arthrocentesis. 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.8–10
The individualized approach used in this study, which in-
volves 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. Our 2×2
reference plane consistently provided better alignment with the
zygomatic arch in all patients, reducing the variability observed
with the HH plane. By doing so, we achieved greater ease in
FIGURE 5. The image illustrates the placement of arthroscopic
instrumentation in the temporomandibular joint region. The image
demonstrates the spatial arrangement of the surgical entry points, forming an
equilateral triangle with 2×2 cm sides to guide precise port placement for
superior joint space visualization. Points A, B, and C are marked as entry sites
for levels I, II, and III of arthroscopy, ensuring optimal alignment with anatomic
landmarks to facilitate access, minimize tissue damage, and improve the
reliability of surgical outcomes.
Rodríguez et al The Journal of Craniofacial Surgery Volume 00, Number 00, ’’
4Copyright © 2024 by Mutaz B. Habal, MD
Copyright © 2024 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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trocar placement, reduced operative time, and minimized
complications. Specifically, the average duration of level III
procedures using our technique was reduced to 6 minutes
compared with 11 minutes with the HH line, demonstrating the
increased efficiency and reproducibility of this approach.
Our study’s complication rate further highlights the im-
portance of meticulous technique. Temporal artery hemorrhage,
observed during procedures using the HH line, illustrates the
risks associated with inadequate spacing between surgical ports.
By providing more reliable entry points, our approach reduced
complications linked to trocar placement. In addition, 3D re-
constructions of temporal artery branches show the vicinity of
this vascular structure, as shown in the study by Liao et al,11
emphasizing the need for precise anatomic planning to avoid
vascular complications.
In terms of clinical outcomes, our study showed statistically
significant improvements in muscle pain, headache, and pre-
auricular pain following the procedure (see Supplemental Ta-
ble 2, Supplemental Digital Content 1, http://links.lww.com/
SCS/H228 for further details). The improvements in these
symptoms were associated with the refined technique, which
facilitated more effective access to the joint space, allowing for
thorough treatment of joint pathology. This was particularly
important in cases of Wilkes III and IV, which represented the
majority of the cases treated in this study. Furthermore, our
data demonstrated significant associations between improved
symptom relief and more efficient surgical times, contributing to
enhanced patient outcomes and satisfaction.
Our findings align with the work of Monje, McCain, and
others, who advocate for precision and flexibility in TMJ ar-
throscopy. By incorporating patient-specific measurements and
a multiport system, our technique represents a shift from
standardized to tailored approaches, particularly for complex
cases involving disc displacement and degenerative joint
disease.12–15
CONCLUSION
This study introduces a more efficient and precise approach to
TMJ arthroscopy for accessing the superior joint space. By
utilizing customized CT-based measurements with the 2×2 ref-
erence plane, we achieved greater efficiency, accuracy, and re-
producibility compared with traditional methods. This
technique reduces operative time and complications, including
facial nerve neuropraxia and temporal artery injury, positioning
it as a valuable advancement in TMJ arthroscopy. Despite the
need for advanced imaging, this tailored approach offers a
streamlined and effective solution for TMJ arthroscopic
procedures.
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The Journal of Craniofacial Surgery Volume 00, Number 00, ’’ Advances in TMJ Arthroscopy Technique
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