1
Q
What is the difference between synovitis and chondromalacia of the TMJ?
A
- Synovitis involves inflammation of the synovial lining of the TMJ, leading to pain and swelling.
- Chondromalacia involves the softening or degeneration of the cartilage within the joint, resulting in pain, clicking, and joint dysfunction.
2
Q
Grading of chondromalacia
A
- Grade I: softening of cartilage
- Grade II: furrowing
- Grade III: fibrillation and ulceration
- Grade IV: crater formation and subchondral bone exposure
3
Q
Grading of synovitis
A
- Type 1 minimal vasodilation, no hyperemia
- Type 2 moderate vasodilation, early hyperemia
- Type 3 considerable vasodilation, moderate hyperemia
- Type 4 total hyperemia, completely obliterates vascular patterns
4
Q
Rib Harvest Technique
A
In adults 12–17 cm of rib can be harvested and 7–10 cm in children
- 5cm incision is made in the inframammary crease
- Dissection is carried through the subcutaneous tissue, fascia, and the plane between the pectoralis major and rectus abdominis.
- Two fingers are used to straddle the fifth and sixth intercostal space.
- Rib 6 is the most commonly harvested as the incision falls in the inframammary crease creating a better cosmetic outcome (fusion of the rectus and pectoralis major forms an avascular plane.)
- A sharp incision is cut through the periosteum down to the outer cortex of the rib.
- A molt periosteal now can be used to dissect in a subperiosteal plane around the rib.
- A sharp blade is used to make the cartilaginous incision. In children it is important to harvest no more than 3 mm (no less than 1 mm) to avoid overgrowth of the rib and to prevent separation of the cartilaginous cap.
- The rib is pulled laterally and a protected rib cutter is now used to section the length of desired rib.
- Check for pleural tears by filling the cavity with normal saline and have the anesthesiologist perform a Valsalva maneuver to check for bubble formation.
- The periosteal sleeve is now closed with 3-0 polyglactin (this may promote de novo regeneration of the missing rib in the child patient).
- The fascia between the rectus and pectoralis major is closed with a 3-0 resorbable suture, followed by subcutaneous tissue and finally skin.
- Post-operatively a chest X-ray is ordered to rule out a missed pneumothorax or hemothorax.
- The patient may return to normal activity post-op day 7, but any strenuous activity is withheld for 6 weeks.
5
Q
How fat prevents heterotopic bone in TMJ reconstruction?
A
- Prevents dead space and formation and organization of hematoma
- Acts as a barrier between the temporal bone and ramal stump
- Have stem cells and potentiality for lipogenesis, adipogenesis, and angiogenesis and induction properties to adjacent lipocytes for lipogenesis
- Pluripotent cells prevents heterotopic bone formation, fibrosis and calcification
- Lubrication and ease in postoperative mouth opening
- Improved range of motion
6
Q
CCG rational:
A
- Physiologic compatibility to TMJ
- Maintains ramus height.
- Has growth potential.
- Acts as interpositional barrier for reduction of reankylosis
7
Q
Approach to the Facial Pain/ Temporomandibular Joint Section
A
- CC – Always ask the patient to expound on the chief complaint.
- HPI (HPI – Use the OLD CARTS acronym)
- Onset – when did the issue start? Was there a history of trauma?
- Location – where is the issue anatomically? For example, have the patient point to the region of discomfort.
- Duration – how long has the pain or decrease in opening been going on?
- Character – describe the character of the pain (throbbing, sharp, or dull).
- Aggravating/associated symptoms – is there anything that makes it worse? Do you have headaches, bruxism, clenching, gum chewing, nail biting, tinnitus, neck pain, or ear pain? Does your bed partner report any nocturnal bruxing? History of open or closed locks? Does your bite feel normal?
- Relieving – is there anything that makes the issue better?
- Timing – has this happened before? Any recent increase in life stressors? Does the pain improve during the day (nocturnal bruxism discomfort regularly improves during the day) or in the evening (arthritic joints tend to have more pain with continued function)?
- Severity – on a scale from 1 to 10, how severe are the symptoms? Is function impaired? Is there difficulty with mastication? Is there difficulty with speech due to pain? How has this affected your quality of life?
8
Q
Surgical Technique for TJR
Preauricular Approach
A
- Incision is marked in the preauricular crease.
- The incision is made through the skin and sub- cutaneous tissues for the entire length.
- Attention is then directed to the superior portion of the incision.
- Dissect through temporo- parietal fascia (TP) and auricularis anterior muscle down to the temporalis fascia layer (which is recognized by the glistening white color).
- Remember the temporal branch of the facial nerve runs within the TP fascia anywhere from 8 mm to 35 mm (average 20 mm) from the bony anterior extent of the external auditory meatus.
- The remaining intervening tissues are dissected down to the level of the temporalis fascia using a nerve monitor/stimulator to avoid the course of the nerve.
- Palpate the zygomatic arch. Incise through the attached periosteum. Dissect subperiosteally until you appreciate the joint capsule.
- Make an incision in the periosteum of the lateral aspect of the condylar head, in a T shape fashion, to expose the lateral aspect of the condyle.
- Dissect subperiosteally to expose the anterior and posterior regions of the condylar neck.
- Pack site and direct attention to the submandibular region.
9
Q
Surgical Technique for TJR
Submandibular Approach
A
- Mark mandible 2 cm below inferior aspect of the mandible.
- Inject vasoconstrictor.
- Make an incision approximately 6 cm long.
- Dissect through skin and subcutaneous tissue to the level of the platysma.
- Undermine skin flap in all directions.
- Sharp dissection through platysma exposing superficial layer of the deep cervical fascia.
- Dissect through this layer with the aid of nerve stimulator/monitor testing for marginal mandibular nerve, which is within or deep to the fascia.
- (Don’t forget Dingman and Grabb study – 19% of the time, the marginal mandibular nerve passed below the inferior border of mandible until it crossed facial artery 1 cm below the inferior border of the mandible).
- Marginal mandibular nerve has two branches 61% of the time and 21% it is a single branch.
- Dissect out facial artery and vein; isolate and clamp and tie vessels.
- Hayes-Martin maneuver – ligation of facial vein (posterior to facial artery) at the lower border of the mandible aiding in reflection of the superficial layer of the deep cervical fascia preserving the marginal mandibular nerve.
- Divide the pterygomasseteric sling along the inferior border of the mandible (the most avascular portion of sling).
- Redirect attention to the preauricular region.
10
Q
Condylar Resection (Condylectomy)
A
- Condyle retractors placed to isolate the neck of the condyle (may not be possible in large ankylotic masses).
- Resect exposed condyle (a minimum of 15 mm of clearance for condyle and fossa component) if additional condyle neck requires removal, may place bone clamp on inferior border and displace ramus superiorly, further exposing condyle neck into preauricular/endaural incision.
- Inadequate removal may lead to impingement of ramus remnant on fossa prosthesis when MMF placed.
11
Q
Fossa Preparation
A
- Removal all soft tissues from tympanic plate to remnant articular eminence.
- TMJ Concepts® – if necessary, reproduce any fossa contouring noted on preoperative model. TMJ concepts will require verification of seating by using the fossa-seating tool.
- BIOMET® stock joint requires manipulation of a specially designed diamond rasp or burr to modify the articular eminence. This allows positioning of fossa component.
- The surgeon must choose the appropriate fossa from sizers to ensure tripod stability.
- Note, the articulating surface of the fossa component stays constant and the amount of screw hole positions over the arch increases with size.
- Secure fossa component (make sure to apply firm pressure with fossa seating tool from TMJ concepts).
- Place only two screws for securing the prosthesis to allow check for the range of motion/ interferences and to avoid damage to bone stock if repositioning is required.
12
Q
Condyle Component
A
Condyle Component
- Place patient in MMF.
- Biomet®, choose correct mandibular component from the sizers.
- Contour bone of the lateral ramus (rarely needed with TMJ concepts due to it having a custom fit) to allow passive fit of BIOMET sizer.
- Secure with two screws at this time.
13
Q
Final Screw Securement
A
Final Screw Securement
- Cover open wound sites, enter oral cavity, and remove MMF. (Consider paralysis at this time for freedom of movement).
- Ensure ROM is at least 32–35 mm.
- If cannot achieve ROM, perform coronoidectomy (first ipsilateral and if not bilateral).
- Note: If this is an ankylotic case, a coronoidectomy is required per Kaban protocol.
- Place final screws, at least four screws for fossa component and six in ramus.
- Irrigate sites and close.
- Consider fat graft around fossa to prevent ankylosis.
I use oxidized regenerated cellulose (Surgicel SNoW®) mixed with antibiotics, take 14 days to resorb in area that has good blood supply and 4-6 weeks in area has less blood supply
14
Q
What is synovial chondromatosis:
A
rare condition involving the abnormal growth of cartilage within the synovial lining of the temporomandibular joint.
15
Q
How would you make decision weather you use custom TMJ vs stock joint?
A
Its depend on severity of the case , patient anatomy , cost, and availability.
16
Q
Sunburst pathology in the TMJ, what is your DD?
A
Osteosarcoma, chondrosarcoma, metastasis process.
- Osteosarcoma: Rare aggressive malignant tumor that arise from the osteoblast.
- TMJ osteosarcoma resection with 3 cm margins and 2 cm overlying soft tissue and post op chemotherapy
- Chondrosarcoma: Rare malignant tumor that arise from cartilage cells.
- Treatment: low grade resection with 1.5cm , 5 years survival >80%. High grade 3cm margin resection and neck dissection.
17
Q
Lactated ringers
A
crystalloid solution containing calcium chloride, potassium chloride, and sodium lactate. It is close to human serum in makeup; therefore, it is best tolerated by the tissues.
18
Q
What do you inject into the joint after?
A
2 cc mixture of 10 mg/ml hyaluronic acid and Kenalog® 40 mg/ml
19
Q
What is Hyalgan?
A
Glycosaminoglycan analog that lubricates and protects the joint surface by preventing phospholipid destruction
20
Q
Mitek anchors
A
cylindrical pins with wings measuring 1.8 mm in diameter and 5 mm in length.
Body is a titanium alloy (90% titanium, 6% aluminum, and 4% vanadium) and the wings are nickel-titanium alloy (Nitinol). There are two strands of single O suture attached to any eyelet to allow anchoring of the disk.
21
Q
The definition of T2
A
the time that it takes for the transverse magnetization to decay to 37% of its original value.
22
Q
The definition of T1
A
the time that it takes for the longitudinal magnetization to reach 63% of its final value
23
Q
Topazian ankylosis classification:
A
Stage 1 – only condyle involved Stage 2 – extends to sigmoid notch Stage 3 – entire condyle, sigmoid notch, and coronoid
24
Q
What would you expect to see in patient with TMJ disorder?
A
- Jaw pain with tenderness of the muscles of mastication
- May see wear facets of the dentition.
- Scalloping of the tongue.
- Morsicatio buccarum
- Patients may complain of sore teeth.
- Decreased range of motion.
- Buccal exostoses
25
Describe your TMJ examination?
- I would perform a physical exam inspect, palpate, auscultate.
- Evaluate for facial asymmetries.
- Palpate muscles of mastication, denoting any pain. Palpate and auscultate TMJ for joint noises and crepitus. Evaluate maximal incisal opening and freedom of movement. I would note any irregular jaw movements and at what length of opening.
- Exam dentition for signs of attrition and compensatory hyperuption, overall dental condition, and premature contacts, and look for morsicatio buccarum and linguarum.
-lateral excursive (normal ~10–12 mm), and protrusive movements (normal ~8–11 mm).
- I would try to elicit a Mahan sign.
26
What is Mahan’s sign?
TMJ pain when biting on tongue blade on contralateral canine
27
What you expect to see in the scan for chronic TMJ patient ?
- Flattening or irregularity of the condylar head due to bone remodeling from chronic stress.
- Osteophytes (small bone spurs) around the condyle as a response to degeneration.
- Decreased joint space in the TMJ area, indicating cartilage loss.
- Sclerosis of the condylar head or articular eminence, showing increased bone density from chronic load-bearing.
28
Patient has pain when palpating along external oblique ridge, what does this tell you?
Temporalis tendinitis
29
Naproxen
nonsteroidal anti-inflammatory drug (NSAID primarily works by inhibiting the action of an enzyme called cyclooxygenase (COX) 1 and 2 but mainly 2.
30
Cyclobenzaprine
muscle relaxant primarily works by blocking nerve signals (or pain sensations) to the brain. It's used short-term to treat muscle spasms
31
What is the difference between T1 and 2?
a. T1 has short TE (echo) and TR (repetition) time and T2 has long
b. T1 illuminates fatty tissue, gives better detail of anatomy
c. T2 illuminates water, shows inflammation better and effusion.
On both T1- and T2-weighted image, the disk and cortical bone will appear black due to low proton density.
32
What fluid do you use? How much? Lactated ringers.
- 100 mL: probable minimum for therapeutic lavage
- 200 mL: reduces protein, TNF, bradykinin, IL-6
- 300–400 mL: no detectable protein, bradykinin
33
Describe a diagnostic sweep
-Medial synovial drape, pterygoid shadow, retro discal tissue, posterior slope of eminence, articular disc, intermediate zone, anterior recess
34
TMJ Anatomy facts
- The temporomandibular joint (TMJ) is a ginglymoarthrodial joint with translational movement in the superior joint space and rotational movement in the inferior joint space
The capsular ligament is lined by the synovium, which functions to provide nutrition and immunosurveillance and lubricates the joint.
Two functional ligaments are the collateral ligaments and the temporomandibular ligaments.
The accessory ligaments are the sphenomandibular and the stylomandibular ligaments.
The articular disk is composed of fibrocartilage.
Blood supply to TMJ superficial temporal, maxillary, and masseteric arteries.
Nerve supply from auriculotemporal with contributions from the masseteric and posterior deep temporal nerve.
35
Myofascial Pain Dysfunction (MPD) etiology
- Parafunctional habits such as bruxism, nail biting, clenching, or gum chewing.
- Life stressors.
- Apertognathia and/or overjet greater than 6 mm.
- Lack of posterior dentition
36
Conservative tx for TMD
NSAIDS Naproxen
muscle relaxant flexril
occlusal appliance
soft diet
warm compressors
Occlusal equilibration
Trigger point injections
Botox intramuscular injections
Replacing the posterior dentition Physical therapy
37
TMJ Non-inflammatory Degenerative Joint Disease (aka Osteoarthritis)
Imbalance between catabolic and
anabolic processes. This leads to expression of catabolic cytokines (TNF-alpha, IL-1, IL-6)
38
TMJ Inflammatory Arthritis
- Joint destruction due to an inflammatory arthritic process (e.g., rheumatoid arthritis (RA), juvenile rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, ankylosing spondylitis, reactive arthritis).
39
Internal Derangement
of the Temporomandibular Joint
Definition.
Disorder of the TMJ in which the articular disk is in an abnormal position as it relates to the condyle and fossa when the teeth are in occlusion.
40
Wilkes classification
Stage I: Painless clicking, no limited mouth opening
Stage II: Painful clicking with intermittent locking. ADDWR, disk thickening
Stage III: Frequent painful clicking with severe limitation in range of motion. ADDWOR. Disk displaced anteromedially
Stage IV: Restricted range of motion with chronic pain and joint crepitus. osseous changes
Stage V: Joint pain and crepitus, The disk is perforated with noted severe osseous changes
41
True ankylosis
intra-articular fusion within the joint space resulting in hypomobility.
* Can be bony, fibrous, or fibro-osseous.
* Can be complete vs. incomplete.
* Can be caused by trauma, infection, otitis media, rheumatoid arthritis, psoriatic arthritis, prolonged immobilization, and previous TMJ or orthognathic surgery.
42
Pseudoankylosis
Extra-Articular Causes
Muscle fibrosis secondary to radiation, myofascial pain, tumors, infection, hysteric trismus, myositis ossificans.
43
Treatment options for ankylosis
Excision of the mass with reconstruction.
The goal of MIO is 35 mm and greater. In an adult, the reconstruction is more commonly achieved with TJR
(other options include costochondral graft (CCG) or fibula free flap).
44
The Seven-Step KABAN Protocol
Dr. Kaban described a protocol for the treatment of TMJ ankylosis in pediatric patients:
* Aggressive resection of the fibrous and/or bony ankylotic mass.
* Coronoidectomy on the affected side and measure MIO intraoperatively.
* Coronoidectomy on the contralateral side if you cannot achieve an MIO >35 mm and/or to the point of dislocation of the unaffected TMJ.
* Lining of the TMJ with a temporalis myofascial flap or the native disk (if salvageable).
* Reconstruction of the ramus condyle unit with either distraction osteogenesis (DO) (activate 2–4 days) or CCG and rigid fixation (10 days of MMF (Maxillary-Mandibular Fixation).
- If DO is used to reconstruct the ramus condyle unit, reshape the native bone narrowed and rounded. A corticotomy is then created distally to serve as transport disk.
- The distraction is set at 1 mm/day. Mobilization begins the day of the operation.
- In patients who undergo CCG reconstruction, mobilization begins after 10 days of MMF.
- DO takes advantage of the fibrocartilaginous cap that forms on the advancing front of the distracted bone heading toward the fossa.
- Early mobilization of the jaw.
- Aggressive physiotherapy.
45
Pneumothorax
air is trapped between the visceral and parietal pleural cavity.
one-way valve allowing air to enter and not escape
Clinically the patients will have labored (tachypneic) breathing, chest pain, tachycardia, hyper- resonance of chest wall on the affected side with diminished breath sounds. Late findings include cyanosis, distension of neck veins, tracheal deviation, and a decreased level of consciousness.
Radiographically can appreciate tracheal deviation, loss of pleural lines, and loss of vascular markings
46
Treatment of Pneumothorax
Treatment firstly is 100% oxygen therapy to reduce the alveolar concentration of nitrogen
A pneumothorax 10% or less in size can be left to reabsorb and serial chest X-rays are indicated
If it does not resolve in 1 week, a tube thoracostomy
Complete collapse of the lung is a 100% pneumothorax. If immediate pressure release is required, needle decompression can be done by placing an IV catheter at the second intercostal space along the mid-clavicular line and listen for rush of air. This procedure will normally buy time for tube thoracostomy. Tube thoracostomy requires a 2–3 cm incision that is marked at the fifth intercostal space just above the top of the sixth rib. Local anesthetic is infiltrated in the skin and tissues. A proximal end of a thoracotomy tub is clamped and advanced over the sixth rib, avoiding the neurovascular bundle on the inferior border of the fifth rib. The tube is placed on water-sealed suction drainage.
47
Pleural Tear
air bubbles may be appreciated during the Valsalva maneuver indicative of a pleural tear. A suction catheter is placed into the wound and a purse string suture through the tear. The suction catheter is removed under suction while tightening the purse string simultaneously.
48
Treatment for Chronic Dislocation
intra-articular injections of a sclerosing agent such as alcohol or autogenous blood in the superior joint space.
Glycerol (Glycerin) induces localized inflammation and mild fibrosis of the joint capsule and synovium.
Botox has also been used in the lateral pterygoid.
LeClerc/Dautrey procedures (zygomatic arch osteotomies)
eminectomy
lengthening the articular eminence with a bone graft (calvarium, symphysis, ramus).
49
What to notice in TMJ area in panoramic
- Joint space
- Bone changes
- Osteophytes
- Subcortical cysts
- Chondromatosis (joint mice)
50
TMJ MRI Facts
TMJ MRI – get T1- and T2-weighted (non- contrast) open and closed mouth views.
Assess disk position with function, disk integrity, and condition of the condyles.
T1 gives better detail of joint anatomy.
T2 useful for inflammatory changes and effusions.
Look for the position of the disk and whether there is deformation.
Remember in T1 fat is bright, T2 water is bright. Can look at the brain in T2 and note the brightness of the gyri and periorbital tissues.
51
Arthrocentesis
Indications are for acute closed lock, previous surgery with continued discomfort, TMJ arthralgia, Wilke’s classification 1, 2, and 3.
Contraindications – ankylosis, overlying skin infection, and inability to appreciate the regional anatomy (i.e., obese patients).
Can be done under local anesthesia or sedation.
52
Arthrocentesis procedure
- Use a marking pen to draw out the canthal- tragal line (aka Holmlund-Hellsing line):
First point is 10 mm ahead of the line and 2 mm below.
Second point is 20 mm ahead (10 mm anterior to the first line) and 10 mm below.
First point corresponds to the deepest point of the glenoid fossa and second point corresponds to the height of the articular eminence.
Prepare skin with antiseptic solution.
Manipulate the jaw to open the joint space.
Insufflate superior disk space with a 27-gauge needle with lactated ringers.
Using an 18-gauge needle, aim the needle at a 45-degree angle superiorly and anteriorly to reach the lateral aspect of the zygomatic arch, then walk the needle off the bone to enter the superior joint space. This will be your anterior port. (Joint entry with needle on average is 25 mm from skin.) Average superior joint space is around 3 cc.
Place posterior port in similar manner with 18-gauge needle (of note a Shepard cannula can also be used which has an entry and exit port).
Irrigate with lactated ringers (at least 100 ml). Lavaging the joint can break up adhesions, which can allow the disk to recapture into its premorbid position. This also irrigates out inflammatory mediators.
Remove anterior port and inject a single agent or combination of steroid (Kenalog 40 mg/ ml), hyaluronic acid (10 mg/ml), local anesthesia (bupivacaine 0.5% with 1:200 K epi), and morphine (10 mg/ml).
Manipulate joint under anesthesia and check opening under sedation.
53
Why we dont use epi when we inject during TMJ procedures
Use local anesthetic without epinephrine to anesthetize the area. This allows early evaluation if concern for traumatic versus anesthetic palsy of facial nerve. Additionally, if planning for diagnostic arthroscopy, epinephrine may mask erythema, rendering findings inaccurate.
54
Otitis Externa
Infection of external auditory canal. Patient will complain of pain on movement or pressure of ear.
Otoscopy will reveal edematous EAC with possible discharge. Treatment includes topical fluoroquinolone otic products (to cover pseudomonas
most common bacteria implicated in otitis externa).
55
Otitis Media
Inflammation of the middle ear structures. Patient will complain of ear pain, difficulty hearing, and fever.
Otoscopy shows full or bulging tympanic membrane or possible purulence (if there is perforation of tympanic membrane).
Treatment includes antibiotics such as amoxicillin. Consider consult with ENT for myringotomy tubes.
56
TMJ Rupture/Hemotympanum
otoscopy to examine for TM rupture or hemotympanum. Consult ENT for intra-op examination if this is noted. If EAC is damaged, place an antibiotic impregnated sponge dressing. This is sutured to maintain opening of the EAC, thereby, preventing stenosis. Some physicians will place on antibiotic-hydrocortisone suspension for 14 days post-op and monitor for granulation tissue formation. This granulation tissue can be removed with bipolar cautery or silver nitrate.
57
Violation of the Middle Cranial Fossa
keep in mind that the fossa is approximately only 0.9 mm thick.
If a large perforation is noted, an intraoperative neurosurgical consult is recommended (as it may be able to be treated immediately).
If you suspect CSF leak postoperatively, then obtain a CT scan/MRI. A tracer study should also be taken. (Neurosurgery should be consulted and should advise on the desired imaging.) The patient is placed on bed rest, with the head of the bed raised greater than 30 degrees. Some advocate administration of antibiotics such as cotrimoxazole as this is bactericidal and enters CSF. The overwhelming majority of small leaks spontaneously heal within 1 week.
58
Damage to the Temporal Branch of the Facial Nerve
The temporal branch of the facial nerve on average is 2 cm anterior to the bony external auditory canal. The classic study of Al-Kyat and Bramley identified a range of 0.8 cm to 3.5 cm.
The temporal branch of the facial nerve innervates the frontalis, orbicularis, and corrugator supercilii.
Most injuries resolve in 3–6 months and, therefore, observation is warranted. Treatment should be reserved for those who are symptomatic. Ophthalmologic consult is indicated. Lubrication and taping of the eye at night are necessary to prevent keratoconjunctivitis.
Physical therapy with electrical stimulation may aid in maintaining muscle tone while awaiting recovery.
Gold weights implants can be placed in the upper eyelid for more permanent defects.
59
Auriculotemporal Nerve Syndrome (Frey Syndrome)
signs and symptoms include gustatory sweating, flushing, and warmth over the temporal and preauricular areas. It results when there is auriculotemporal nerve damage and occurs most commonly with arthroscopy.
It usually is temporary and will resolve within 6 months.
The patient is to be evaluated with the Minor test (starch iodine). A solution of 3 g iodine, 20 g castor oil, and 200 ml absolute alcohol is applied to both preauricular regions of the face.
Gustatory sweating is elicited by having the patient chew on a lemon drop. A positive test is conversion of the yellow mixture to a dark blue. Case reports have shown that 16–80 IU of botulinum A subcutaneous injection has resulted in resolution within 1 week.
Other treatments are application of scopolamine ointment (anticholinergic properties) and surgical transection of the innervation.
60
Bleeding During Condylotomy
During the condylotomy, the concern for bleeding is from the internal maxillary artery (IMA) and its branches. The IMA runs 3 mm medial from the mid-sigmoid notch and 20 mm below the condylar head. A commonly damaged vessel, as the cut is made through the sigmoid notch, is the masseteric artery.
61
Bleeding During Diskectomy
many times during a diskectomy, the bleeding may be also originating from the retrodiscal tissues or the lateral pterygoid muscle.
The most commonly damaged vascular structure is the middle meningeal artery. It is found on average 31 mm medial the zygomatic arch and an average of 2.4 mm anterior from the height of the glenoid fossa.
The first step to managing bleeding is to establish visualization. Attempt to identify any vessels for cauterization or ligation. If no obvious source, then apply firm pressure with a moistened gauze packed tightly into the wound.
Additional hemostatic measures include thrombin-soaked gauze, flowable hemostatic agents, collagen sponges, or tissue adhesives. The inferior border of the mandible is then displaced superiorly to aid in pressure hemostasis (holding pressure for at least 5 minutes). Interventional radiology for embolization is warranted immediately if bleeding is not controlled by local hemostatic measures.
62
Total TMJ Joint Replacement
Total joint replacement (TJR) indications:
* Failed previous TMD surgeries
* Severe arthritic joint
* Loss of vertical mandibular height and occlusal relationship
* Pathology
* Ankylosis – either bony or fibrotic
* Condylar agenesis
63
Two Approved TJR Prosthetics in the USA
1. Biomet®
* Stocked with multiple sizes
* Chromium cobalt alloy for condylar component and ultra-high molecular weight
polyethylene for fossa component.
* Pseudotranslation possible (if unilateral placement due to push of contralateral
TMJ).
* Chromium cobalt mandibular prosthesis is
offered in three sizes (45 mm, 50 mm, and 55 mm) and in three styles (standard, narrow, and offset).
* Chromium cobalt may contain nickel (a consideration in those with a nickel allergy).
64
How will you evaluate nickel allergy?
LTT - Lymphocyte Transformation Test - Haptens pick up metal ions and show immune response $400.
SPT: Skin Patch Test - Langerhans Cells - not reliable for metal ions
- insurance covers, not so good.
65
Two Approved TJR Prosthetics in the USA
TMJ Concepts®
* Custom made w/CT scan and
stereolithography.
* Mostley titanium but the articulating surface is chromium cobalt, which has nickel.
Titanium with ultra-high molecular weight polyethylene for the fossa component.
66
MRI contraindication?
MRIs should not be taken with patients with implanted ferromagnetic metals. These include AICD and clips to treat aneurysms.
67
TMJ condylotomy. What is the rationale for it use?
The goal is to increase the joint space and unload the disk to relieve pain by allowing some condylar sag.
It is accessed like an IVRO with medial pterygoid muscle release to allow for condylar sag.
The posterior cut is made 6–8 mm from the posterior border and 10 mm from the sigmoid notch. The amount of sag is assessed by looking at the inferior border and the tip of the proximal segment. The goal is to achieve 3–4 mm of sag.
68
What is your post-op protocol for a condylotomy?
– Post-op orthopantogram
– 7 days of IMF (unilateral) for 14–21 days (bilateral)
– Elastics and physical therapy
– Remove arch bars off in 7 weeks
69
How can you reduce the incidence of heterotopic bone formation?
Most cases occur 2–3 months after surgery. Most important it is to regain range of motion as soon as possible.
Total radiation dose of 10 Gy to 20 Gy has been reported via fractionated daily doses in the immediate post-op phase.
Wolford reported use of fat graft around the joint to decrease heterotopic bone formation.
Indomethacin, a non-selective COX inhibitor, has been compared to radiation treatment in prevention of heterotopic bone formation in hip arthroplasty and found to be equally effective. It is given in 75 mg doses for 6 weeks (along with pantoprazole).
70
Patient after total joint replacement returns with a red and swollen preauricular region. What do you do?
Examine external auditory canal for concern of perforation. If a superficial infection is suspected, remove some sutures to establish drainage, obtain cultures, and prescribe a short course of oral antibiotics.
If no improvement or recurrence, get a CT image with contrast to rule out deeper infection (a return to OR for aggressive debridement and/or removal of components may be indicated).
71
Wolford protocol for management of acute infection after TJR
Acute Infection (Within 5 d of Onset of Infection)
1. Infection identified
2. Broad-spectrum antibiotics started
3. Infectious disease consult
4. Surgery
a. I/D, C&S, debridement
b. Prosthesis scrubbed with toothbrush and Betadine solution
c. Placement of irrigating catheters/drains for 4-5 d
5. Irrigation of catheters every 4 h with double antibiotic solution for 4-5 d, then catheters/drains removed
6. PICC line placed
7. IV antibiotic therapy based on C&S
8. Outpatient IV antibiotics for 4-6 wk
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Wolford protocol for management of chronic infection after TJR
Chronic Infection (1 mo After Onset of Infection)
1. Infection identified
2. Broad-spectrum antibiotics started
3. Infectious disease consult
4. Surgery stage I
a. I/D, C&S, debridement, prosthesis removed
b. Placement of acrylic spacer with or without antibiotic
c. Placement of irrigating catheters/drains
5. Irrigation of catheters every 4 h with DAB for 4-5 d, then drains/catheters removed
6. PICC line placed
7. IV antibiotic therapy based on C&S
8. Outpatient IV antibiotics for 4-6 wk
9. Surgery stage II
a. Reconstruction with new prosthesis at 8-10 wk
b. Placement of fat graft around articulating area of prosthesis
10. IV antibiotics until discharge
11. Outpatient oral antibiotics for 10 d
- A tobramycin spacer is made from polymethyl methacrylate (PMMA)
- Tobramycin is an aminoglycoside antibiotic that inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit
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What clinical malocclusion is present in End-stage TMJ pathology, with b/l condylar degeneration
loss of posterior vertical height high occlusal plane angles
Class II malocclusions
anterior open bite
decreased airway space
In unilateral:
- Ipsilateral posterior open bite
- Contralateral crossbite or deviation
- The mandible deviates toward the affected side during closure
- Facial asymmetry: The affected side appears shorter due to the condylar collapse, leading to a tilted occlusal plane.
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Stock vs custom TJR
Stock devices:
- Readily available
- Limited in sizes and shapes
- Reduced cost
- Patient’s anatomy needs to be adapted to the prosthesis, which may pose challenges.
- Not recommended or approved for mandibular advancement procedures.
- Custom:
- Pt specific
- Address severe dentofacial deformities that require significant mandibular advancements
- Presence of a posterior stop in the glenoid fossa component to prevent dislocation of the
- Require longer waiting times
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Why we can not use stock device with dentofacial deformity or if we plan to do large mandible advancement ?
with significant mandibular advancements, the angle of the stock prosthesis becomes acute and increases the risk of posterior dislocation since the stock glenoid fossa component does not have a posterior stop to prevent posterior dislocation of the condylar component.
Additionally, in patients with congenital disorders, a stock prosthesis could not be properly adapted to fit the altered anatomy.
76
The initial goal of the physical therapy
20 to 25 mm at 4 weeks ,30 to 35 mm at 8 weeks and over 35 mm at 12 weeks.
If the patient has not met the goal at eight weeks, a formal physical therapy consult is initiated
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Idiopathic Condylar Resorption
Autoimmune disorder causing chronic synovitis in the TMJ, leading to cartilage destruction, progressive, bilateral, and symmetric condylar resorption followed by stabilization without further loss of height if resorbed down to sigmoid notch; no consistent or inciting event or etiology.
* Females, age 15 to 35 years
* Most often teenage girl during pubertal growth spurts
Physical findings
* Generally good TMJ function but some TMJ discomfort and muscle hyperactivity during active phase of condylysis
* Thinning and flattening of condylar heads
* Decrease in condylar height
* Loss of posterior facial height
* Mandibular retrusion
* Class II malocclusion with apertognathia
Work-up
Techetium-99m bone scan may be useful to determine if condylysis is active.
Laboratory Tests:
Inflammatory markers:
ESR (elevated in active inflammation).
CRP (may be elevated but not specific).
Autoimmune markers:
ANA (positive in ~50% of JIA cases, particularly in oligoarticular JIA).
Rheumatoid factor (RF) (positive in RF-positive polyarticular JIA, but usually negative in TMJ JIA).
Treatment
* Treatment is controversial
* Orthognathic surgery if condylysis is inactive but may reactivate the resorption (bilateral sagittal split
osteotomy [BSSO] may be associated with relapse)
* TMJ reconstruction
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WHAT IS HUMIRA (adalimumab)?
It is a monoclonal antibody that targets tumor necrosis factor-alpha (TNF-alpha)
79
Normal Maximum Interincisal Opening (MIO)
Normal Maximum Interincisal Opening (MIO) 40-45mm
lateral excursive (normal ~10–12 mm)
protrusive movements (normal ~8–11 mm).
80
Patient with right TMD, where the jaw will be deviated?
To the right side d/t weakness of lateral pytergoid muscle , inflammation and edema around the affected joint.
81
What kind of splint you use for TMD and myalgia pts?
There are only two kinds of splints.
1- Flat plane, which, yeah, we use that to help with TMJ issues
2- Anterior guided splints. So, basically, it's going to deload the amount of pressure that you can put on your jaw. So, patients who have myalgia or clenching, those actually tend to work better. The issue with anterior guided splints is they do load the joint a little bit.
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Incidence of facial nerve injury with preauricular and sub mandibler approach?
5-15 % temporary
Around 1% permanent
83
What is the blood supply to TMJ
* What is the blood supply to TMJ: superficial temporal arteries, masseteric artery, maxillary artery
* Nerve supply to TMJ: auriculotemporal, contributions from masseteric and posterior deep temporal nerve
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How do you determine if there is still growth in unilateral condylar hyperplasia?
Growth activity is determined using a SPECT/bone scan. If the affected condyle shows >10% higher uptake than the contralateral condyle, or uptake exceeds 55%, it indicates ongoing growth and abnormal activity.
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What is a SPECT scan
Nuclear medicine tomographic imaging technique using gamma rays, detects growth activity (i.e. condylar hyperplasia, viability of failed free flap)
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JIA/JRA
o JIA/JRA – autoimmune inflammatory condition lasting > 6 weeks in a patient < 16 yrs old; Dx of exclusion
Subtypes – systemic, polyarticular, oligoarticular, psoriatic,
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What is Frey syndrome?
Gustatory sweating and flushing on the cheek during eating or salivation. It occurs due to aberrant regeneration of auriculotemporal nerve fibers, which innervate sweat glands instead of salivary glands.
ABOMS OCE 2024
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