Indications and Outcome of TMJ Athros

Indications and outcome
of TMJ arthroscopy
Dr Bobby John, MDS, MOMSRCS(Edin), MFDSRCPS ( Glasg), FIBCSOMS, FIBOMS,

Associate Professor, Dept of OMFS,
GDC Kottayam.
Internal Derangement
• LOCALISED MECHANICAL FAULT INTERFERING WITH SMOOTH ACTION OF JOINT

HEY&DAVIS
• A DISTURBANCE IN THE NORMAL ANATOMIC RELATIONSHIP BETWEENTHE DISC

AND CONDYLE THAT INTERFERES WITH SMOOTH MOVEMENT OF THE JOINT
LASKIN AND CAUSES MOMENTARY CATCHING,CLICKING,POPPING OR LOCKING
• ANY INTERFERENCE WITH SMOOTH JOINT MOVEMENT

CNA
2008
TRADITIONAL TREATMENT
Conservative Minimally
Splint Adjunct Invasive TJR
or NS invasive
PYRAMID of Treatment
Joint replacement
• Prosthetic
• Autogenous
• Pharmaco Therapy
• Splint Therapy Discectomy & Arthroplasty
Disc repositioning
• Arthroscopic
• Arthrotomy
Arthroscopy &
Arthrocentesis
HIERARCHY OF TREATMENT
OPTIONS IN TMDs
PARADIGM SHIFT
Current role and future of MITJS
The basic operative techniques that have been described
are as follows:
Single puncture
v Arthroscopic lavage (AL)—diagnostic arthroscopy with
lavage (Level I)
v Arthroscopic lysis and lavage (L&L)—diagnostic
arthroscopy, lavage & “blind sweep” (Level I)
v Arthroscopic lysis, lavage, needle working instrument
(Level II)
Double puncture with triangulation

v Treatment/removal of pathology/debridement (Level III)
v Disc repositioning (Level III)
MOA
The success of ALL lies primarily in

1. Irrigation of joint,
2. Distension of joint space,
3. Reducing friction,
4. Washout of inflammatory cytokines and
5. Lysis of adhesions.
(Hamada Y, Kondoh T, Holmlund AB, Nakajima T, Horie A, Saito T, Nomura Y, Seto K.

One-year clinical course following visually guided irrigation for chronic closed lock of
the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006;101:170–4.)
Indications for MIO - AAOMS
1.ID of the TMJ, mainly Wilkes stages II, III, and IV
2.Degenerative joint disease (osteoarthritis)
3.Synovitis
4.Painful hypermobility or recidivist luxation of discal cause
5.Hypomobility caused by intra-articular adherences
Gonzalez-Garcıa R, Gil-Dıez Usandizaga JL, Rodrıguez-Campo FJ.

Arthroscopic anatomy and lysis and lavage of the temporomandibular joint.
Atlas 1549 Oral Maxillofac Surg Clin North Am 2011;19:131–44.
Other indications in literature
1.Inflammatory arthropathies (systemic arthritis)
2.Articular symptoms subsidiary to orthognathic surgery
3.Revision of the TMJ in cases of intra- articular implants

CONTRAINDICATIONS
• Cutaneous, otic, articular infections
• Tumor with risk of extension
• Severe fibrous or bony ankylosis

TRIBUTE TO
STALWARTS
Ohnishi
Murakami
Joseph McCain
Relevance
• Diagnostic
• Therapeutic
Terminologies
• ACL, SACL
• CCL
• 3 month window period
Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal

derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 1986;62:361–72.
Disc - eminence complex
Medial synovial drape
•
Posterior slope of eminence
Retrodiscal synovium
Roofing
The concept of roofing evaluates the covering of the articular

disk over the condyle.
Roofing is graded arthroscopically according to the posterior

band of the articular disk and its position relative to the
articular eminence.
The roofing concept: A, 100%; B, 50%; C, 0%.
BRONSTEIN MERRILL – WILKE’S
HOLMLUND AND HELSING LINE
Retro discitis / synovitis
Normal
Anatomy
Creeping synovitis
Normal Anatomy
Disc perforation
Viscosupplementation
❖ Sodium hyaluronate increases the concentration and

molecular weight of HA in the synovial fluid
❖ Restoring tissues lubrication and nutrition as well as

minimizing mechanic stress.
❖ Analgesic effect by blocking receptors and endogenous

substances that cause pain in synovial tissues.
❖ Promotes a release of adhesion areas between the articular

disc and the mandibular fossa, increasing joint mobility and
allowing better synovial fluid circulation.
• Steroids
• Tramadol
• PRP, PRF
TRIANGULATION TECHNIQUE by
McCain
Alligator forceps for debris removal,
biopsy procedures
Radiofrequency Coblation for tight adhesions
ARTHROSCOPIC DISCOPEXY
The results of the present study have shown that TMJ

arthroscopic discopexy is an effective and predictable
treatment of patients with TMJ ID in whom primary TMJ
arthroscopy failed. Our results have also shown that patients
with Wilkes II or III TMD will have the most successful
outcome.
ARTHROSCOPIC DISCECTOMY
Arthroscopic discectomy for treatment of large disc

perforations seems to provide an effective treatment for
TMJ pain and dysfunction, decreasing the pain and
improving the range of motion.
Newer techniques
SEVERE ADHESIONS IN IJS
OUTCOMES
• Positive
• Negative
Erickson and Westesson success criteria
(1) A visual analogue score (VAS) score of less than 20

(2) MIO of 35 mm or more
Eriksson L, Westesson PL. Temporomandibular joint diskectomy. No positive effect of
temporary silicone implant in a 5-year follow-up. Oral Surg Oral Med Oral Pathol
1992;74:259–72.
OHNISHI’s REVIEW
In the last three decades, arthroscopy has shown best efficiency

for functional recovery in terms of jaw range of motion for
patients with painful limited jaw opening (closed lock) among the
nonsurgical treatment, arthrocentesis, and open arthrotomy.
Arthroscopic surgery appears to be a safe,
minimally invasive, and effective method for
treating internal derangements of the TMJ.
Though they’re cousins
Arthrocentesis and arthroscopic lavage are the two different

approaches to lavage and arthrolysis. Although both these
procedures are having similar success rates, arthroscopic lysis
and lavage is found to be more efficient in terms of
improvement in range of motion and pain reduction.
(Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of

internal derangement of the temporomandibular joint: a systematic review
and meta-analysis. Int J Oral Maxillofac Surg. 2015 Jan;44(1):104-12. doi:
10.1016/j.ijom.2014.07.008. Epub 2014 Aug 7. PMID: 25123511.)
ALL with blind sweep
Elimination of Suction cup effect of articular disc to

glenoid fossa and lysis of adhesions are facilitated
by sweeping with a blunt probe during ALL.
(Sanders B: Arthroscopic surgery of the temporomandibular joint:

Treatment of internal derangement with persistent closed lock. Oral
Surg Oral Med Oral Pathol 62:361, 1986)
Negative outcomes
A comparison of the literature shows that although their

effectiveness is essentially the same, arthrocentesis is simpler,
has less morbidity, and has fewer complications than
arthroscopic surgery.
• It was found that the distance from the lateral rim of the fossa to
DP and Hugier's canal was 9.50 _+ 2.07 mm and 17.04 _+ 3.09
mm, respectively.
• The most dangerous angle for DP injury in the Frankfort

horizontal plane (FH plane) was an inclination of the instrument
base of -8 ° dorsad and 17 and 19 ° caudad in the frontal plane.
Complications
In the frontal plane, the most dangerous angles of the
instrument base were 17 and 19 ° caudad.
Perforation of the
tympanic membrane
Re-arthroscopy
FUTURE ADVANCEMENTS
OUR DUTY -
TRAINING THE
YOUNGER
GENERATION
It takes a village to raise a child’ and it takes a large team to
comprehensively describe temporomandibular disorders
(TMDs) and to accurately and safely examine, identify,
understand, treat, and manage these extremely widespread
musculoskeletal pain conditions.

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Indications and outcome

Dr Bobby John, MDS, MOMSRCS(Edin), MFDSRCPS ( Glasg), FIBCSOMS, FIBOMS,

• LOCALISED MECHANICAL FAULT INTERFERING WITH SMOOTH ACTION OF JOINT

• A DISTURBANCE IN THE NORMAL ANATOMIC RELATIONSHIP BETWEENTHE DISC

• ANY INTERFERENCE WITH SMOOTH JOINT MOVEMENT

Double puncture with triangulation

The success of ALL lies primarily in

(Hamada Y, Kondoh T, Holmlund AB, Nakajima T, Horie A, Saito T, Nomura Y, Seto K.

1.ID of the TMJ, mainly Wilkes stages II, III, and IV

2.Degenerative joint disease (osteoarthritis)

4.Painful hypermobility or recidivist luxation of discal cause

5.Hypomobility caused by intra-articular adherences

Gonzalez-Garcıa R, Gil-Dıez Usandizaga JL, Rodrıguez-Campo FJ.

1.Inflammatory arthropathies (systemic arthritis)

2.Articular symptoms subsidiary to orthognathic surgery

3.Revision of the TMJ in cases of intra- articular implants

• Cutaneous, otic, articular infections

• Tumor with risk of extension

• Severe fibrous or bony ankylosis

• 3 month window period

Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal

The concept of roofing evaluates the covering of the articular

Roofing is graded arthroscopically according to the posterior

❖ Sodium hyaluronate increases the concentration and

❖ Restoring tissues lubrication and nutrition as well as

❖ Analgesic effect by blocking receptors and endogenous

❖ Promotes a release of adhesion areas between the articular

The results of the present study have shown that TMJ

Arthroscopic discectomy for treatment of large disc

(1) A visual analogue score (VAS) score of less than 20

In the last three decades, arthroscopy has shown best efficiency

Arthrocentesis and arthroscopic lavage are the two different

(Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of

Elimination of Suction cup effect of articular disc to

(Sanders B: Arthroscopic surgery of the temporomandibular joint:

A comparison of the literature shows that although their

• The most dangerous angle for DP injury in the Frankfort

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