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
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