1
Q
What kind of joint is the the TMJ
A
Ginglymoarthroidal joint with rotation and translational movement
2
Q
Nerve supply of TMJ
A
Auriculotemporal
3
Q
Vascular supply of the the TMJ
A
Internal Maxillary artery, superficial temporal and masseteric arteries
4
Q
Treatment of Mascatory myalgia
A
NSAIDS, occlusal appliances, soft food diet, warm compresses, cyclobenzaprine 5-10 mg nightly, trigger points, and botox, replacing posterior dentition
5
Q
What are the catabolic cytokines in osteoarthritis
A
IL 6, 1 TNF A
6
Q
Which vector does a disk displace in internal derangement
A
anterior and medial
7
Q
Know Wilkes Classification
A
Based on clinical and radiographic severity
1. painless clicking, disc displacement with reduction
2. occasionally painful clicking, occasionally locking, disc displacement with reduction
3. Frequent painful clicking and locking, does not reduce
4. Signs of degeneration of the disc, some changes of osseous components
5. Severe degeneration of disc and osseous changes CREPITUS
8
Q
What are the Sawhney and Topazian classifications of ankylsos
A
Sawhney
1. No bony bridging
2. No medial bony bridging
3. Connection of ramus and the zygomatic arch
4. Wider bony bridges replacing architecture.
Topazian.
1. Condlye involved
2. Sigmoid notch involved
3. All and coronoid involved.
9
Q
7 step Kaban protocol for treatment of TMJ ankylosis in peds patient, Also what for postoperative management
A
- Aggressive resection of ankylosis
2 . Coronoidectomy on same side - Coronoidectomy on opposite side if not over 35 mm
- Lining TMJ with temporals flap or disc
- Reconstruction with Distraction osteogenesis or costochondral graft and 10 days of rigid fixation.
- Early mobilizations
- Aggressive physiotherapy.
10
Q
How much rib graft can be harvested and which ones
A
Adults can get up to 15, Kids 10 Harvest from rib 6 on the right so its not confused with cariogenic pain .
11
Q
Rib harvest technique
A
- Incision made in the inframammary crease (5cm)
- Dissecct to junction of the rectus abdomens and pec.
- Straddle the fifth and sixth intercostal space and cut through periosteum, then use rib cutter
- Fill with saline for pleural tears, and have anesthesia perform a valsalva.
- periostea sleeve is closed with 3-0 polyglactin,
- Chest xray to rule out pneumothorax, day 7 can return to normal activity.
12
Q
What are rib harvest complications
A
- Separation of the cartilaginous cap and the rib, can drill a hole and reattach is.
- pneumothorax, witll have labored breathing, achy cardia, chest pain, and hyper resonance. Needs oxygen, those less than 10 percent can be left to resorb, 2.5 cm margin of gas is 30 percent. else at 1 week a chest tube must be placed in midclavicular line at 5th intercostal space.
- Pleural tear, can put a suction catheter through and do a purse string tie.
13
Q
How to do a tube thoracotomy, and a needle decomrpssion
A
Needle decompression is IV Cath at 2nd intercostal at mid clavicular.
14
Q
What bandage do you place on the head after jaw reduction for open lock
A
Barton bandage
15
Q
Treatment of chronic dislocation
A
Blood into the joint or sclerosis agent like alcohol
16
Q
T1 imagining, what is bright, what does it evaluate, what color are the gyro of the brain
A
T1 fat is bright, better at looking at anatomy because in the condyle, the marrow is fat. Gyri has no white.
17
Q
T2 imagining what is bright and what is grey, what is it better to look at
A
Water is bright, better for looking for bleeds or edema or fusions. , brain gyro is white and brain is grey.
18
Q
TMJ work up: OLD CARTS
A
Onset
Location
Duration
characterization
Aggrevation
relives
Timing
Severity
19
Q
What is Mahans test
A
If you bite on a stick and the opposite side hurts, possible internal derangement in the opposite side.
20
Q
Contraindications for arthocentesis
A
Overlying infection. ankylosis, inability to appreciate regional anatomy.
21
Q
Holmund Hellsing line
A
canthal tragal line, 10 and 2 and 20 and 10
22
Q
How to do an arthrocentesis
A
- Draw your HH line
- Anesthetize your injection sites. Start aiming superiorly and walk your needle down and insufflate with lidocaine.
- Use and 18 gauge and enter your superior then inferior joint spaces.
- Lavage with lactated ringers.
- Add 10 mgm /ml hyaluronic acid and kenelog 40mg/ml and bupivicaine
23
Q
What is average superior joint space, and how deep is the joint entry
A
3 cc and 25mm from skin
24
Q
What to irrigate with and how much
A
LR as it has potassium chloride, calcium chloride, and sodium.
25
What to inject and how much
around 1.5 cc
26
Which Wilkes for disk reposition procedure
2-5
27
What is the Al Kayat extension, what is the pre auricular incision
increases the access
Make an incision along the pre auricular crease through skin and sub q to the Temporoparietal fascia, make an incision through the superior TPF and dissect downwards with a nerve stimulator like checkpoint, Incise through the temporals fascia, towards the zygomatic arch, dissect subperiosteally to the joint capsule, insufflate and make an oblique cut.
28
Where does the temporal branch of the facial nerve run within the TP fascia, what's the average
usually 20 mm in front of the external auditory canal, between 35-8.
29
What vector do you plicate the disc with what
Posterior lateral with mitek anchors. or none resorabable sutures
30
What are the complications of this
1. Otitis Externa perf
2. Otitis Media perf
4. Ankylosis
5. Broken instruments
6. TMJ rupture
7. Violation into the middle crania fossa
8. Damage to the temporal branch
9. Auricle temporal nerve syndrome
10. Bleeding during condylotomy
11. Bleeding in discectomy
31
Otisis Externa what does it seem like and treatment
Pain or pressure of air, otoscope will have edema EAC with discharge. Treatment includes topical fluoroquinolone
32
Otitis Media symptoms and treatments
Similar symptoms, swelling tympanic membrane. Treat with amoxicillin and consult ENT for myringotomy tubes.
33
What to do for TM rupture/hemotympanum
ENT consult, if EAC is damaged placed abx impregnanted sponge sutured to maintain opening.
Can place abx hydrocortisone suspension for 14 days post op for granulation tissue formation.
34
Violation of the middle cranial fossa and how thick is the fossa, how long does it take to spontaneously
Bone is 1 mm thick, large perf needs nsgy, post of CT if suspect of CSF leak. As well as tracer study. Patient needs Head of bed elevated and Bactrim. most seal within 1 week.
35
What does the temporal branch of the facial nerve innervate, who should u consult and what to be done,
forehead, and eyelids (frontalis, corregator, and oculi. ) most within 3-6 months , needs to consult optho, for golden plate placement and eyedrops with taping of eye to prevent keratoconjuntivities.
36
Sings of Auriculotemporal nerve syndrome (Freys), how long it resolves How to test for it.
gustatory sweating, flushing, and warmth of temporal and pre auricular areas. Because of auriculotemporal nerve damage. usually resolves within 6 months. Minor test: you put iodine and castor oil and alcohol on the preauricualr area on the skin, they chew on a lemon drop, from yellow to dark blue is positive. You can inject 16-80 of botox has resolved within 1 week. Also scopolamine ointment.
37
Bleeding during condylotomy , where does it run
usually from I max, usually 3 mm medial from mid sigmoid notch and 20 mm below the condylar head. also masseteric
38
Bleeding during discectomy, which bleed is usual artery, how to manage
from lateral pterygoid muscle or retrodiscal tissues. Most common damage is the middle meningeal, is 31mm medial to zygomatic arch and average of 2.4mm anterior to the height of the glenoid fossa. Can put thrombin soaked gauze or collagen sponge.
hold pressure by moving up the mandible, if nothing works IR
39
how is a carotid cut down done
Some surgeons advocate
carotid artery cut down for uncontrollable bleed-
ing. Some question its efficacy due to contralat-
eral circulation. In this approach, the neck
incision is extended (a horizontal incision 5 cm in
length) 2 cm below the inferior border of themandible, over the sternocleidomastoid muscle
(SCM). The SCM is retracted posteriorly, and
with blunt dissection parallel to the vessels, the
carotid sheath should be identified. The SCM is
carefully dissected from the sheath and the sheath
is carefully entered. The internal jugular vein
should be retracted posteriorly to reveal the com-
mon carotid. Dissection to the bifurcation aids in
identification. The hypoglossal nerve will cross
the arteries above this bifurcation and should be
identified to prevent damage. Ligation should be
above the facial branch, third of the anterior
branches. Blood flow has been found to be
reduced by 73%, when ligated at this position
40
Indications total joint replacement
Failed previous TMD surgeries
Severe arthritic joint
Loss of vertical mandibular height and occlu-
sal relationship
Pathology
Ankylosis – either bony or fibrotic
Condylar agenesis
41
What is approved for TJR
1. Biomet®
*
Stocked with multiple sizes
*
Chromium cobalt alloy for condylar com-
ponent 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, nar-
row, and offset).
*
Chromium cobalt may contain nickel (a
consideration in those with a nickel
allergy).
TMJ Concepts®
*
Custom made w/CT scan and
stereolithography.
*
Pure titanium for condylar component.
Pure titanium with ultra-high molecular
weight polyethylene for the fossa
component.
42
How is TJR done
Preauricular Approach
*
Standard preauricular approach to joint cap-
sule (see above).
*
Make an incision in the periosteum of the lat-
eral aspect of the condylar head, in a T shape
fashion, to expose the lateral aspect of the
condyle. Of note, the anatomy may be dis-
torted due to an ankylotic mass and, therefore,
recognizable anatomical landmarks should be
used as a reference for the dissection.
*
Dissect subperiosteally to expose the anterior
and posterior regions of the condylar neck.
*
Pack site and direct attention to the subman-
dibular region.
Submandibular Approach
*
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 man-
dibular nerve, which is within or deep to the
fascia.
*
(Don’t forget Dingman and Grabb [8] 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 avas-
cular portion of sling). Redirect attention to
the preauricular region.
Condylar Resection (Condylectomy)
*
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 preauricu-
lar/endaural incision.
*
Inadequate removal may lead to impingement
of ramus remnant on fossa prosthesis when
MMF placed.
Fossa Preparation
*
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 seat-
ing 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 pros-
thesis to allow check for the range of motion/
interferences and to avoid damage to bone
stock if repositioning is required.
Condyle Component
*
Place patient in MMF.
*
Biomet®, choose correct mandibular compo-
nent 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.
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 coronoid-
–
ectomy (first ipsilateral and if not
bilateral).
– Note: If this is an ankylotic case, a coro-
–
noidectomy 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.
Post-op
*
Post-op radiographs to confirm position and
alignment.
*
Post-op exercises and soft diet.
*
Consider physical therapy for 4–6 weeks
43
what does wingman and grab say
Don’t forget Dingman and Grabb [8] 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
44
What is the Hayes Martin Maneuver
Ligation and dissection of the facial vein inferiorly to reflect and protect the marginal mandibular nerve
45
what Is in lactated ringers, how much do you use
100 mL: probable minimum for therapeu-
–
tic lavage
– 200 mL: reduces protein, bradykinin, IL-6
–
– 300–400 mL: no detectable protein,
–
bradykinin
46
When do you use a condylotmy
47
How to reduce heterotrophic 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 fraction-
ated daily doses in the immediate post-op
phase. Wolford reported use of fat graft around
the joint to decrease heterotopic bone
formatio
48
what is the mnemonic for external carotid branches
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Maxillary
Superficial Temporal
