Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock

oral surgery oral medicine oral pat hology

with sections OH endodontics and dental radiology Volume 62. Zmnbcr 4. Octobw IF96

oral surgery

Editor: ROBERT B. SHIRA, D.D.S.

School of Dental Medicine, Tufts University I Kneeland Street Boston, Massachusetts 02111

Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock Bruce Sanders, D.D.S.,* Santa Monica and Los Angeles, Calij

SAINT JOHN’S HOSPITAL AND HEALTH CENTER, SANTA MONICA, CALIF., AND UNIVERSITY OF CALIFORNIA AT LOS ANGELES SCHOOL OF DENTISTRY

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. (ORAL SURG. ORAL MED. ORAL PATHOL. 62~361-372, 1986)

P ersistent closed locking of the temporomandibular joint (TMJ) has been attributed to internal derangement due to anterior disk displacement with- out reduction. Anatomic, arthrographic, clinical, and surgical studies have supported this concept.lV9 The natural history of internal derangement leading to persistent closed lock has been described by IrelandlO and by Dolwick and associates.” Trauma to the mandible has been reported to be a common etiologic factor leading to the development of internal derangement with closed lock.‘* The traumatic event may result not only in disc displacement but also in

*Adjunct Professor, Section of Oral and Maxillofacial Surgery, UCLA School of Dentistry; Staff Oral and Maxillofacial Sur- geon, Saint John’s Hospital and Health Center, Santa Monica. Calif.

Fig. 1. Distension of the superior compartment with saline or lactated Ringer’s solution.

361

362 Sanders old SUrg. October, 1986

-.

Fig. 2 A, Sheath for 1.9 mini-arthroscope. B, Sharp and blunt trocars that are inserted into sheath.

Fig. 3. Inflow and outflow mechanism.

intracapsular microbleeding and effusion. As a result, disk surface friction and disk fibrillation occur. Subsequent adhesions may form. These adhesions are most commonly seen in the superior compartment.*12 In addition, morphologic changes, including synovitis and synovial hyperplasia, occur in the TMJ.13, I4

Treatment of acute closed locking of the TMJ may include mandibular manipulation and splint therapy. These modalities are intended to “recapture” or reduce the displaced disk. If noninvasive therapy is not successful, a persistent closed lock will be present. Temporomandibular joint surgery via arthrotomy (an open surgical approach) has been widely advocated for treatment of internal derangements with closed lock when nonsurgical therapy has failed. Preauricular, endaural, and postauricular approaches have been employed by various clini- cians. Disk repositioning, arthroplasty, meniscecto-

*RotskofT, K.: Personal communication, 1985; Ryan, D.: Personal communication, 1985.

Fig. 4. A, Camera and light source attached to arthroscope. B, Placement of arthroscope with camera attachment.

my with implant, and other procedures for treating internal derangement have been described.15

The purpose of this article is to present an alternative approach to the surgical correction of internal

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Arthroscopic surgery of temporomandibular joint 363

SUPERIOR COMPARTMENT - POSTERIOR RECESS

Fig. 5. The surgeon views the superior compartment on the video monitor. A video recorder is part of the arma- mentarium.

Fig. 6. A, Diagram of superior compartment-posterior recess.

Fig. 6 (Cont’d). B, Posterior attachment adjacent to posterior fossa wall with left TMJ in closed position. C, Left posterior attachment with partial opening. D, Note normal vascularity of posterior attachment.

36 i4 Sanders Oral S urg. October. 1 986

Fig. 6 (cont’d). E and F, Posterior attachment with left TMJ open. G and H, Closed and open left posterior recess showing posterior disk and posterior fossa wall.

coMpART.E* SUPERIOR

DESCENDING ASPECT OF CENTRAL PORTION OF DISC

Fig. 7 A, Diagram of superior compartment-descending aspect of central portion of disk.

derangement of the temporomandibular joint with closed lock. This treatment includes arthroscopic inspection of the superior compartment and lysis (resection, ablation) of adhesions that form between

the disk and the fossa concomitant with disk displacement. These disk-fossa surface adhesions possi- bly prevent relocation of the displaced disk by nonsurgical methods. These superior-compartment adhesions have been documented with arthrography,* and other surgeons and I have noted these adhesions during arthrotomy. Adhesions in the superior compartment may render the disk nonreducible. With the use of an elevator during the arthrotomy procedure, the adhesions can be released and the disk may appear to move normally again. Solberg** has observed adhesions in cadaver specimens.

ARTHROSCOPY OF THE TEMPOROYANDIBULAR JOINT

In 1975 Ohnishi18 first described the application of arthroscopy to the temporomandibular joint. Ohni-

*Ross, J.: Personal communication, 1985. **Solberg, W.: Personal communication, 1985.

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Fig. 7 B, Clinical view of descending aspect of central portion of disk of left TMJ.

COMPARTMENT -

Fig. 8. A, Diagram of superior compartment-ascending aspect of central portion of disk.

Fig. 8 B. Clinical view of ascending aspect of central portion of disk of left TMJ.

SUPERIOR COMPARTMENT -

ANTERIOR RECESS

Fig. 8. A, Diagram of superior compartment-anterior recess.

Fig. 8. B. Clinical view of anterior recess of left TMJ.

Adhesions

A 8

Fig. 10. A, Diagram of superior compartment adhesions associated with persistent closed lock.

shi,‘9.20 Kinq21.22 and Murakami23-29 and their col- leagues have produced excellent papers on arthroscopic findings in cadavers. They have described important arthroscopic anatomic landmarks, reported on arthroscopic pathology, and developed arthroscopic terminology.

Hilsabeck and Laskin)O and Williams and Laski#

366 Sanders Oral Surg. October. 1986

Fig. IO (Cont’d) B, posterior adhesions of left TMJ. Note irregular synovial surface of posterior fossa wall. C, Anterior adhesions of left TMJ. Note heavy synovial mass adhering eminence to ascending aspect of central portion of disk of left TMJ. D, Massive adhesions of disk and fossa anteriorly in region of eminence of left TMJ.

technique have been described by Murakami and Ono.29

Murakami and colleaguesz5~ *‘, 29 have reported successful therapeutic arthroscopic treatment in patients with TMJ closed lock. Forcible insertion of an arthroscopic trocar (blunt probe) between the fossa and the disk, with a “sweeping” action of the trocar, resulted in ablation of surface adhesions. Thus, the disk became mobile, and the closed lock was eliminated. The procedure presented in this article is a variation of Murakami’s technique.

ARTHROSCOPIC TECHNIQUE

Fig. 11. Synovitis of left TMJ.

conducted TMJ arthroscopic investigations in rab- bits to determine the possible diagnostic applications of this technique. Diagnostic temporomandibular joint arthroscopy has been reported by few authors.‘9, Z. 33, 34 Arthroscopic instrumentation and

Arthroscopy is done in the operating room while the patient is under general anesthesia with nasoen- dotracheal intubation. All procedures begin with arthroscopic examination. Definitive treatment with arthroscopic surgery or arthrotomy is determined by arthroscopic findings. The arthroscopic technique begins with the assistant surgeon manipulating the

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Fig. 12. Hyperemia of right posterior attachment and posterior recess of right TMJ in patient with 2-week-old closed lock and painful capsulitis.

Fig. 13. Arthroscopic sweep for lysis of adhesions eliminate TMJ persistent closed lock.

Art hroscopic Sweep:

Lysis of Adhesions

Fig. 14. Arthroscopic lysis of adhesions with blunt trocar.

mandibular condyle anteriorly and inferiorly. The compartment (Fig. 2). The blunt trocar replaces the superior compartment is entered with a 20-gauge sharp trocar, and a minimal sweeping action creates needle, and 1 to 2 ml of 0.5% lidocaine with space between the disk and the fossa. The inflow 1:200,000 epinephrine is injected. Next, 3 to 4 ml of mechanism is established, and a separate outflow normal saline solution or lactated Ringer’s solution is mechanism is created via a separate anterior portal injected (Fig. 1). A 1.9 mm mini-arthroscopic sharp (Fig. 3). The 1.9 mm arthroscope replaces the blunt trocar in a sheath is used to enter the superior trocar in the sheath. The tube camera and light

366 Sanders Oral Surg. October, I986

Fig. 16, A, Superior compartment adhesions causing closed lock of left TMJ. B, Left TMJ after lysis of adhesion. C, Left TMJ after saline lavage; note ablation of adhesions.

Fig. 16. Lavage technique with suction attached to outflow mechanism.

Fig. 17. Wounds a few days postoperatively.

source are attached (Fig, 4). The arthroscopic examination is visualized on the television monitor and is recorded on %-inch video tape (Fig. 5).

ARTHROSCOPIC EXAMINATION

Arthroscopoic examination of the superior compartment commences in the posterior recess (Fig. 6).

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Fig. 18. Complete elimination of closed lock after arthroscopic surgery. Patient is totally asymptomatic. Note mandibular stabilizing splint.

The posterior attachment and the posterior fossa wall are seen. Next the descending aspect of the central portion of the disk is examined (Fig. 7), after which the ascending aspect of the central portion of the disk is seen (Fig. 8). Finally, the anterior recess, articular eminence, and anterior portion of the disk can be seen (Fig. 9).

Detailed intracapsular pathosis can be documented. Disk and fossa surface stickiness (suction cup effect) and fibrillations along with synovial adhesions in the superior compartment appear to be the primary reason a displaced disk does not reduce and a closed lock persists. These adhesions are most commonly seen in the posterior recess, forming surface adhesions from the posterior attachment to the posterior fossa wall and anteriorly between the posterior slope of the eminence and the central portion of the disk (Fig. 10). Masses of synovial tissue can be seen in patients with chronic inflamma- tion. This synovitis is similar to synovitis in the knee (Fig. 11). Changes in the vascularity of the posterior attachment are easily seen. A hyperemia of the posterior attachment and synovial lining is observed in many cases of closed lock (Fig. 12). Changes in the position mobility, contour, coloration, and thickness of the disk can be observed. Perforations of the disk and posterior attachment can be visualized.

ARTHROSCOPIC SURGERY

Arthroscopic surgery is a highly effective method for releasing disk and fossa surface stickiness and

adhesions that are apparently contributing to a persistent closed lock. Surgical technique consists of an “arthroscopic sweep” of the superior compartment, which lyses (resects) the superior-compartment adhesions (Fig. 13). This maneuver is done with the blunt trocar (Figs. 14). The temporomandibular joint immediately becomes mobile, and condylar translation becomes possible (Fig. 15). The superior compartment is thoroughly lavaged by irri- gation and suction (Fig. 16). A small amount of steroid solution is placed in the superior compartment when the tissues appear inflamed. There is usually no need for any sutures. A pressure dressing is placed but is removed that evening. The patient is usually discharged the next day. The wounds heal rapidly (Fig. 17). Full mandibular opening and excursive movements are present within 1 to 4 days (Fig. 18). A stabilizing (nonrepositioning) bite splint is employed postoperatively.

RESULTS

Forty arthroscopic procedures were done on the TMJ superior compartments of 25 patients. Fifteen patients had bilateral procedures, and ten patients had unilateral procedures. There were twenty-four female patients and one male patient. The age range was 11 years to 51 years, with a mean age of 30 years. All but four patients had preoperative arthro- grams.

The clinical diagnoses were either internal derangement with persistent closed lock or arthrosis. The initial phase of each of the forty arthroscopies

370 Sanders Oral Surg. October, 1986

Table I

No. Patient’s age (yr)

Patient’s sex TMJ

Duration of symptoms

Clinical diagnosis

Radiographic findings

Arthroscopic examination

Arthroscopic surgeq

1 30 2 30 3 41 4 41 5 18 6 18 I 39 8 49 9 49

10 28 11 28 12 20 13 20 14 30 I5 30 16 51 17 51 18 19 19 25 20 25 21 24 22 24 23 23 24 11 25 46 26 35

27 37 28 19 29 19 30 25 31 30 32 32 33 32 34 28 35 28 36 28 37 28 38 21 39 21 40 25

F F F F F F F F F F F F F F F F F F F F F F F F F M

F F F F F F F F F F F F F F

R L L R R L L R L R L R L R L R L L R L R L L L L R

R R L L L R L R L R L R L L

DJD = Degenerative joint disease. CL = Closed lock (persistent). E (follow-up) = Excellent. G = Good. UNK = Unknown, lost to follow-up. E = Eburnation. P = Perforated disk. NRAD = Non-reducing anteriorly displaced disk. A = Adhesions. S = Synovitis. P = Perforated disk.

5 yr 6 mo DJD DJD, NRAD AES NO

2 Yr CL NRAD AS Yes

5 yr DJD DJD EASP No

1 yr DJD DJD EAS Yes

1 yr CL NRAD AS Yes

1 yr CL NRAD AS Yes

6 yr DJD DJD APE No I yr 6 mo CL NRAD AS Yes 1 yr 6 mo DJD DJD AS NO

8 yr DJD DJD ASE Yes

8 yr DJD DJD ASE No 1 yr 6 mo CL NRAD AS Yes 1 yr 6 mo CL NRAD AS Yes

1 v CL NRAD AS Yes

1 v CL NRAD AS Yes

3 yr DJD DJD ASE Yes

3 yr DJD DJD ASE No

2 Yr CL NRAD AS Yes 10 yr DJD DJD ASE No 10 yr DJD DJD ASE No 2 yr 6 mo DJD DJD ASE No

2 Yr DJD DJD ASE No 10 yr CL NRAD AS Yes

yr 6 mo CL NRAD AS Yes yr 6 mo CL NRAD AS Yes

2 yr CL NRAD AS Yes

3 mo CL NRAD AS Yes 3 mo CL NRAD AS Yes 3 mo CL NRAD AS Yes

1 yr DJD DJD ASE No 10 yr DJD DJD ASE No 2 yr CL NRAD AS Yes 2 yr CL NRAD AS Yes 1 yr CL NRAD AS Yes 1 yr CL NRAD AS Yes

6 mo DJD DJD ASE No 6 mo DJD DJD ASE No

11 mo CL, DJD DJD ASEP Yes 11 mo CL, DJD DJD ASE Yes

1 mo CL NRAD AS Yes

was diagnostic. Fourteen of the procedures were followed by arthrotomy with meniscectomy, arthroplasty, and insertion of a silicone fossa implant. Twenty-six of the procedures were therapeutic. Arthroscopic surgery was employed in twenty-one

joints to eliminate persistent closed lock symptoms by lysing superior-compartment adhesions. Saline or lactated Ringer’s solution lavage was an integral part of the procedure. Arthroscopy was therapeutic in five arthrotic joints as well, with lysis of adhesions,

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Arthrotomy

(arthroplasty, Postop. Follow meniscectomy, etc.) (mo.) UP Complications

Yes 10 No 10 Yes IO No 10 No 10 No 10 Yes 10 No 9 Yes 9 No 9 Yes 9 No 9 No 9 No 9 No 9 No 8 Yes 8 No 8 Yes 8 Yes 8 Yes 8 Yes 8 No 8 No 8 No 8 No 8

No 8 No 8 No 8 Yes I Yes I No I No I No I No I Yes I Yes I No I No I No I

E E E E E E E E F G F E E E E E G E G G G G E E G UNK Severe ear infection,

resultant hearing defect

E E E E G E E E E G G E E E

lavage, steroid placement, synovectomy, and partial meniscectomy (Table I).

The initial postoperative course of patients who have undergone therapeutic arthroscopy has been good or excellent. Most cases are now a few to several months postoperative. All patients who had symptoms of closed lock are essentially asymptomatic. They have little preauricular pain and have a good range of oral opening. The arthrosis cases are all significantly improved. Of the forty arthroscopies, only one complication occurred: A severe postoperative middle ear infection developed in one patient

who underwent a unilateral arthroscopy. A hearing defect resulted.

REFERENCES

1. Wilkes CH: Structural and functional alterations of the temporomandibular joint. Northwest Dent 57: 287, 1978.

2. Wilkes CH: Arthrography of the temporomandibular joint in patients with the TMJ pain-dysfunction syndrome. Minn Med 61: 645, 1978.

3. Farrar WB, McCarty WL Jr: Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J Prosthet Dent 41: 548, 1979.

4. Blaschke DD, Solberg WK, Sanders B: Arthrography of the temporomandibular joint: review of current status. J Am Dent Assoc 100: 388, 1980.

5. McCarty WL Jr, Farrar WB: Surgery for internal derangement of the temporomandibular joint. J Prosthet Dent 42: 191, 1919.

6. Dolwick MF, Katzberg RW, Helms CA, Bales DJ: Arthroto- mographic evaluation of the temporomandibular joint. J Oral Surg 39: 793, 1979.

7. Bronstein SL, Tomasetti BJ, Ryan DE: Internal dcrange- ments of the temporomandibular joint: correlation of arthrography with surgical findings. J Oral Surg 39: 572, 198 I,

8. Westesson P-L, Rohlin M: Diagnostic accuracy of double- contrast arthrotomography of the temporomandibular joint: correlation with postmortem morphology. AJNR 5: 463, 1984.

9. Rohlin M, Westeson P-L, Eriksson L: The correlation of temporomandibular joint sounds with joint morphology in fifty-five autopsy specimens. J Oral Maxillofac Surg 43: 194, 1985.

10. Ireland VE: The problem of “the clicking jaw.” Proc R Sot Med 44: 191, 1951.

11. Dolwick MF, Katzberg RW, Helms CA: Internal derangement of the temporomandibular joint: fact or fiction‘? J Prosthet Dent 49: 415, 1983.

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and arthroscopic terminology in human temporomandibular joints. Okajimas Folia Anat Jpn 58: 745-760, 1982. Murakami K, Ito K: Arthroscopy of the temporomandibular joint: arthroscopic anatomy and arthroscopic approaches in the human cadaver. Arthroscopy 6: l--13, 1981 (in Japanese, abstract in English). Murakami K, Ito K: Arthroscopy of the temporomandibular joint third report; clinical experiences. Arthroscopy 9: 49-59, 1984 (in Japanese, abstract in English). Murakami K, Ito K: Arthroscopy of the temporomandibular joint. In Watanabe M (editor): Arthroscopy of small joints, Tokyo, 1985, lgaku Shoin. Murakami K, Matsuki M, lizuka T, Ono T, Hoshino T: Arthroscopic differential diagnoses and treatments of the locking symptoms of the temporomandibular joint and their regional anatomical interpretations, 7th Congress of Europe- an Association for Maxillofacial Surgery in Paris, 1984. Abstr. 89. Murakami K, Matsumoto K, lizuka T: Suppurative arthritis of the temporomandibular joint: report of a case with special reference to arthroscopic observations. J Maxillofacial Surg 12: 41-45, 1984. Murakami K, Ono T: Temporomandibular joint arthroscopy: introduction of an arthroscopic technique by the inferolateral approach. Int J Oral Maxillofac Surg (In press).

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Reprint requests to. Dr. Bruce Sanders Section of Oral and Maxillofacial Surgery UCLA School of Dentistry Center for the Health Sciences Los Angeles, CA 90024

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Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock