TMJ ARTHROSCOPY

BY – DR.DHAVAL TRIVEDI

MDS PART – II

The temporomandibular joint (TMJ) has a more

complicated anatomy and function than any

other human joint.

Its position close to the dense bone of the skull

base makes it difficult to examine clinically and

radiographically.

Improvement of diagnostic methods in this area

is therefore desirable

TMJ Arthroscopy is a technique for direct visual inspection of

internal joint structures, including biopsy and other surgical

procedures performed under visual control which comprises

use of an Arthroscope.

Arthroscopy was first described by Takagi in 1939

Ohnishi in 1975 ,published first report on TMJ arthroscopy

He used no. 24 watanabe 1.7mm telescope

J Oral Maxillofac Surg 47386-389.1989

INDICATIONS

Internal derangement

Osteoarthritis

Arthritides

Pseudotumors

Post-traumatic complaints

To perform biopsy

CONTRAINDICATIONS

Bony ankylosis

Advanced resorption of the glenoid fossa

Infection in the joint area

Malignant tumors

Increased risk for hemorrhage

Increased risk for infection

Fibrous ankylosis

ARTHROSCOPY EQUIPMENT

General: suction, Lactated Ringer’s IV bag for irrigation, marking pen

Specific TMJ instrument set

30-degree arthroscope

0 , 70 ,120 degree

Trocars – sharp & blunt

Canullas

Holomium laser

Fluid infusion system

Shavers Light Cord Camera

PROCEDURE

Performed under G.A or local anaesthesia ccombined

with sedation

Auriculotemporal nerve block & infiltration in

subcutaneous tissue lateral to the joint

Supine position to reduce the risk of inducing a

vasovagal reaction

Upper compartment is distended with 2ml lignocaine

till resistence felt

After 3 ml , distension should be stopped

Inferolateral approach is used to gain good access to posterior

part of upper compartment of TMJ

With this approach access to anterior recess is limited

Best to puncture lower compartment

Anterolateral approach provides better access to anterior recess

of upper compartment

Endural approach give view of lateral part of upper compartment

Lower compartment puncture ????

Telescope should always be used to ensure that the

arthroscopic sheath has been correctly placed

An outflow portal is then created about 5 mm anterior

to & slightly below the sheath

Continuous irrigation is performed using isotonic

saline solution

For longer procedure ringer’s solution should be used

as it protect the chondrocytes & maintain the

synthesis of proteoglycans

Examination begins with identification of landmarks

the boundary between the disk & posterior disk attachment ,

the medial capsule , the inferior part of eminence & anterior

capsule

Posterior disk attachment is the predominant location for

inflammation like increased vascularity , capillary hyperemia ,

synovial hyperplasia

Loss of well defined boundary between posterior part of the

disk & posterior disk attachment indicates degenerative

changes usually found in joints with chronic locking &

osteoathritis

During alternate opening & closing movements, any elongation of

the posterior disk attachment is revealed

The arthroscope the should be moved more medially to visualize

the medial capsule

After that it is directed anteromedially , when mouth is closed

slightly it will slip under eminence into anterior recess

SURGICAL PROCEDURES

Lavage

Lysis

Lateral capsule release

Disk repositioning

Synovectomy

Debridement & Abrasion

Restriction

Intraarticular pharmacotherapy

COMPLICATIONS

Vascular injury

Extravasation

Scuffing

Broken instruments

Otologic complication

Intracranial damage

Nerve injury

Infection

Why arthroscopy ??

It has become an important method for the diagnosis

& treatment of TMD

Its accuracy in diagnosing TMD is high &

simultaneous biopsy can be performed to improve

diagnostic accuracy

Some procedures like lysis & lavage can be done

under L.A

Shorter hospitalization & less cost effective

THANK YOU