Dr.

Nazhat
Mahmood Oral
surgery 5th Stage

LEC.2

Meniscal plication

Most cases of TMD can be managed nonsurgically

with conservative therapy. However, open TMJ surgery
(arthroplasy) might be considered when conservative
measures fail to improve the patient's condition within 4-6
months, and when arthrocentesis or arthroscopy fail to
correct meniscal dislocation.

Open joint arthroplasty with disc plication is the

most conservative open technique. It involves mobilizing the
anteriorly displaced disc and plicating it posteriorly (with
sutures or staples) to ensure that it rests in the correct
anatomical position on the mandibular condyle. Success
rates approaching 90% have been reported.

The usual approach for open joint surgery is via a

preauricular incision (fig. 2). Once the joint is exposed, entry
is made into the upper joint compartment and the position
of the meniscus identified. Any adhesions are released and
the meniscus is repositioned and fixed with sutures from the
lateral aspect of the cartilage and posteriorly into the
temporal muscle and fascia. Some surgeons will also enter
the lower joint space to increase the mobilisation of the
meniscus and remove a wedge of retrodiscal tissue, stitch
or plicate the defect created with retrodiscal sutures,
repositioning the meniscus more posteriorly.

Sometimes these procedures are combined with an

eminectomy to increase joint space. Postoperative management
is similar to that of arthroscopy. Physical therapy is
important as there is inevitably a degree of scarring
following this surgery.
oo

Fig.2 Preauricular incision for TMJ

surgery

Meniscectomy

This procedure is not as common as meniscal placation,

but there have been reports of successful outcomes in patients
suffering from internal joint derangement by this
method. However, there is uncertainty about long-term effects
this may have on the joint. Essentially, the approach is the
same as that for meniscal plication. Once the meniscus is
identified the cartilaginous part is excised.

Meniscectomy involves removal of the disc, and although it

readily eliminates the disc displacement, it may be
associated with signifycant degenerative joint disorders
(DJD) unless it is replaced with some type of graft
(cartilage, fat, and dermis grafts have been used) or flap
(temporalis muscle-fascia flap).

Condylotomy

This technique for treating painful TMJs originally used a

blind external approach using a Gigli saw. Nowadays this
procedure is carried out via an intraoral approach.

The lateral aspect of the ramus of the mandible is exposed

and a cut is made below the condyle with an oscillating
saw. It may be subcondylar or subsigmoid. This causes
reduced pressure on the meniscus and anterior movement
of the condylar head, which
reduces pain and often allows reduction of the displaced
joint meniscus.

The modified condylotomy is an extra-articular procedure

that spares the TMJ itself but involves allowing the
mandibular condyle to reposition inferiorly and anteriorly in
order to facilitate a more normal relationship between the
condyle and disc. This procedure is associated with
significant postoperative occlusal changes that can be
difficult to manage in the long term, especially when done
bilaterally.

Degenerative Joint Disease (DJD) of the

Temporomandibular Joint

Rheumatoid arthritis RA

RA is an auto-immune disease. It usually affects heavy

weight bearing joints, but TMJ may be occasionally
affected. This disorder characterised by proliferation and
outgrowth of the synovial membrane resulting in erosion of
articular cartilage and subchondral bone.

After microvascular injury, synovial cells proliferate and

chronic inflammatory cells infiltrate. Associated production
of proteinases and prostaglandin and collagenases is
responsible for erosions of the joint surfaces.

Clinically there will be intermittent pain, swelling and

progressive limitation of joint motion. As the disease
advances there will be decrease of mouth opening, aching,
stiffness and muscle tenderness.

MRI reveals TMJ disc destruction, displacement and

joint effusion. As the disease process advances there
might be shortening of the posterior ramus.

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Osteo-arthritis

It is chronic non-inflammatory degenerative disease of

the articular cartilage of the joints. It is the most common
skeletal disorder affecting TMJ.

The degenerative changes are believed to result from

dysfunctional remodelling, due to a decreased host-
adaptive capacity of the articulating surfaces and/or
functional overloading of the joint that exceeds the normal
adaptive capacity. The pathological process is
characterized by deterioration and abrasion of articular
cartilage and local thickening with osteophytes formation
and marginal bone thickening leads to palpable masses
over the preauricular region. These changes are
accompanied by the superimposition of secondary
inflammatory changes.
It usually affects patients in the 5th decade and
characterised slow onset with mild symptoms. If it affects
patients younger in age it shows more severe
symptomatic representation. The patient usually complains
from pain in the joint and muscles of mastication, limitation of
mandibular motion and joint crepitus.

Plain radiograph and CT scan may show flattening of

the condylar head, cyst formation of subcondral bone,
joint narrowing, osteophyte formation and subchondral
sclerosis. MRI may reveal disc perforation and dislocation.

Treatment of DJD

At the early stages of DJD conservative measures would

be the option of treatment. Aspirin or NSA medications like
Ibuprofen to minimize inflammation and associated pain.
Muscle relaxant can provide relief from masticatory muscle
spasm/pain and, along with a soft diet, will decrease the
loads delivered across the TMJ articulation under function.
Restoring balanced

11
occlusion especially at the early stages would decrease
the chance of unilateral joint overload.
Attempts at minimally invasive procedures such as
arthrocentesis and arthroscopic surgery may be adequate
to relieve the pain and potentially halt or slow the disease
process. However, with progression of the degenerative
process, more invasive procedures may be indicated.

Advanced DJD is frequently treated with open joint

surgery. Surgical treatment of TMJ DJD can be difficult,
especially in the multiply operated patient. Patients may
present with a history of previous attempts at
arthrocentesis, arthroscopic surgery, and/or open joint
procedures. The surgical procedure of will be based on
the surgeon's preference, training, and clinical diagnosis.
TMJ arthroplasty can be performed with either disc repair,
or disc plication, and osseous recontouring of the condylar
head.

Alternatively, TMJ arthroplasty with discectomy can be

performed. After the disc or disc remnant is removed, the
disc can be replaced with an autogenous fat graft, dermal
graft. In end-stage DJD, total joint replacement or
reconstruction may be warranted.

Condylectomy

Condylectomy is usually performed when there is either

ankylosis or pathology of the TMJ. A preauricular approach
is used and, once the condyle is well exposed, it is cut at
the neck of the joint and removed. This procedure is
generally combined with joint reconstruction.