Surgical approaches to tmj

approaches to TMJ

1. SURGICAL APPROACHES TO TMJ PRESENTATION BY: ADITI RAJVANSHI 3-Mar-17 1

2. contents Introduction Associated surgical anatomy Various surgical approaches and their modifications C omplications References 3-Mar-17 2

3. Temporomandibular joint and its components frequently require exposure for a myriad of procedures. 3-Mar-17 3

4. SMAS Concept given by Teisser & defined by Mitz and P eyronie in 1976. Continuous fibromuscular layer. Synonyms: In scalp – galea aponeurotica In temporal region – temporoparietal fascia, superficial temporal fascia or suprazygomatic SMAS Below zygomatic arch – parotideomasseteric fascia 3-Mar-17 4

5. ASSOCIATED NEUROVASCULAR STRUCTURES 3-Mar-17 5

6. FACIAL NERVE 3-Mar-17 6

7. Distance from the lowest concavity of the external auditory canal to the bifurcation of the main trunk of the facial nerve -1.5 to 2.8 cm. Atlas of temporomandibular joint surgery – Peter D Quinn 2 nd ed

8. From the bifurcation of the facial nerve to the postglenoid tubercle - 2.4 to 3.5 cm. Atlas of temporomandibular joint surgery – Peter D Quinn 2 nd ed

9. The distance from the most anterior concavity of the bony external auditory canal to the most posterior significant temporal branch of the facial nerve - 0.8 to 3.5 cm(Mean 2 cm). Atlas of temporomandibular joint surgery – Peter D Quinn 2 nd ed

10. Temporal branch Liebman et al in 1982, described histologically that the layer in which it travels. They reported that it was locked in the fascial layer between temporalis fascia and subdermal fat superficially. Stuzin et al in 1988, examined the temporal region by cadaver dissection and reported that it lay within the temporoparietal fascia and travels along undersurface of this fascial layer. 3-Mar-17 10

11. A straight trajectory A curved trajectory. Temporal branches of Facial nerve Ishikawa Y: An anatomical study on the distribution of the temporal branch of the facial nerve. J Craniomaxillofac Surg 18:287, 1990 3-Mar-17 11

12. Pitanguy , L, A. S. Ramos: The frontal branch of the facial nerve: The importance of its variation in face lifting. Plast . Reconstr . Surg . 38 (1966) 352 Middelton’s line 3-Mar-17 12

13. 3-Mar-17 13 The new guideline for preservation of the entire temporal branch is drawn with a dashed line. An anatomical study of the distribution of temporal branch of facial nerve. J.cranio-max-fac.surg.18(1990),287-292.

14. An anatomical study of the distribution of temporal branch of facial nerve. J.cranio-max-fac.surg.18(1990),287-292 . 3-Mar-17 14

15. Dingman and Grab Ziarah and Atkinson 3-Mar-17 15 Marginal mandibular nerve

16. MARGINAL MANDIBULAR SURGICAL ANATOMY OF MANDIBULAR DISTRIBUTION OF FACIAL NERVE. ZIARAH & ATKINSON, BJOS 1981;19,159-170 MARGINAL MANDIBULAR BRANCH

17. 3-Mar-17 17 Superficial temporal artery Transverse facial artery Maxillary artery Superficial Temporal Vessels Atlas of human anatomy – Frank H Netter 6 th ed

18. 3-Mar-17 18 Auriculotemporal nerve Auriculotemporal nerve Auriculotemporal nerve Arises from posterior part of mandibular division of CN V Runs beneath lateral pterygoid muscle. Passes from medial surface of condyle & emerges on to the face behind the TMJ within the superior surface of the parotid gland. A scends posterior to the superficial temporal vessels, passes over the posterior root of the zygoma , and divides into superficial temporal branches Atlas of human anatomy – Frank H Netter 6 th ed

19. RETROMANDIBULAR VEIN 3-Mar-17 19 Retromandibular vein Anterior division Posterior division Maxillary vein Superficial temporal vein GRAY’S Anatomy, The anatomical basis of clinical practice – 41 st ed

20. Greater auricular nerve 3-Mar-17 20 Greater auricular nerve largest ascending branch of the cervical plexus arises from the second and third cervical rami, encircles the posterior border of sternocleidomastoid, perforates the deep fascia and ascends on the muscle beneath platysma On reaching the parotid gland, it divides into anterior and posterior branches

21. SURGICAL APPROACHES 3-Mar-17 21

22. types Extraoral approaches Preauricular Endaural Postauricular Coronal Retromandibular Submandibular R hytidectomy Intraoral approaches Intraoral vestibular – without endoscope with endoscope 3-Mar-17 22

23. choice of incision A ccessibility to the joint Avoiding damage to vital neurovascular structures Aesthetic concerns on visibility of post op scars Technique sensitivity and surgeon’s experience In case of ankylosis , choice of interpositioning material. 3-Mar-17 23

24. 3-Mar-17 24 Preauricular incision Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

25. Incision usually is 3-4cm in length consist of 2 limbs – superior curved limb and inferior vertical limb anterior to tragus. Initial incision is made through skin and subcutaneous tissues 3-Mar-17 25 Incision is outlined at the junction of facial skin and helix of the ear.

26. 3-Mar-17 26 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed Dissection

27. Preauricular dissection techniques described in the literature……. - Rowe NL: Surgery of the temporo-mandibular Joint. Proc R Soc Med 65:383, 1972 - Al- Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979 Suprafascial procedure Subfascial procedure Deep Subfascial Approach - Massimo Politi : J Oral Maxillofac Surg 62:1097-1102, 2004 3-Mar-17 27

28. Politi et al. Deep Subfascial Approach to the TMJ. J Oral Maxillofac Surg 2004 3-Mar-17 28

29. Incising temporalis fascia Make an oblique incision parallel to the frontal branch of the facial nerve, through the superficial layer of the temporalis fascia above the zygomatic arch . Begins at the root of zygomatic arch and extends anterosuperiorly towards upper corner of reflected flap 3-Mar-17 29 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

30. Coronal view of dissection to the lateral portion of the zygomatic arch and mandibular condyle region. Insert the periosteal elevator beneath the superficial layer of the temporalis fascia and strip the periosteum off the lateral zygomatic arch. 3-Mar-17 30

31. 3-Mar-17 31 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

32. 3-Mar-17 32 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed Blunt dissection below the zygomatic arch Exposed TMJ capsule

33. 3-Mar-17 33 First incision is through the upper joint space Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

34. 3-Mar-17 34 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

35. 3-Mar-17 35 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

36. Skin closure 3-Mar-17 36 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

37. Modifications of preauricular approach 3-Mar-17 37

38. Blair’s Inverted Hockey Stick Dingman’s Incision Endaural Incision Popowich and Crane Incision Thoma’s Angulated Incision 3-Mar-17 38

39. Al kayat and bramley 3-Mar-17 39 Skin incision is question mark shaped Begins antero -superiorly within the hairline & curves backwards and downwards well posterior until it meets upper ear attachment Incision then follows ear attachment endauraly A modified pre-auricular approach to the temporomandibular joint and malar arch British Journal of Oral Surgery 17 (1979-80), 91-103

40. 3-Mar-17 40 A modified pre-auricular approach to the temporomandibular joint and malar arch British Journal of Oral Surgery 17 (1979-80), 91-103

41. 3-Mar-17 41 Advantage: less bleeding fascial planes can be easily identified excellent visibility good cosmetic result

42. dingman Incision is started in the fold at the junction of anterior margin of helix Carried downwards to upper portion of tragus where it is contained inside the margin of tragus to anterior fold of lobule It again becomes visible at this point and is carried downwards to lower attachment of ear 3-Mar-17 42

43. Anatomy of ear 3-Mar-17 43

44. Endaural approach 3-Mar-17 44 First described by Lempart as an approach to mastoid process for surgical improvement of otosclerosis for approaching TMJ Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

45. The Endaural Incision Incision begins well within the EAM at superior meatal wall The incision is carried carefully through the skin over the tragal cartilage at a 90- degree angle to the most convex part of the tragus itself . The incision is carried superiorly to the uppermost portion of the auricle and then extends in approximately a 45 degree angle into the temporal hairline for about 3 to 4 cm. 3-Mar-17 45

46. incision is deepened to temporoparietal fascia continued inferiorly with knife in continuous contact with the tympanic plate sharp dissection is done along the perichondrium the flap is raised en masse anteroinferiorly 3-Mar-17 46

47. Comparison of standard preauricular and endaural surgical approaches Advantages: Most of the vital structures are in a superficial plane. Very good access to the joint and also the coronoid process. Excellent esthetic result with minimal post operative scar Disadvantage : Esthetic compromise if tragal projection is lost Risk of possible perichondritis 3-Mar-17 47

48. A Modified Endaural Approach to the Temporomandibular Joint J Oral Maxillofac Surg 51:33-37,1993 3-Mar-17 48 ADVANTAGES: Broad based flap with excellent blood supply Possibility of residual cartilaginous deformity is less Damage to CN VII is unlikely

49. 3-Mar-17 49

50. A new modified endaural approach for access to the temporomandibular joint. British Journal of Oral and Maxillofacial Surgery (2001) 39 , 371–373 3-Mar-17 50

51. Postauricular approach Descibed by Alexander & James Incision is placed in the grove between the helix and post auricular skin Pre-op considerations described by Walter and Geist: History of normal scar formation Healthy auditory system with no infection No TMJ infection 3-Mar-17 51 Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

52. The post-auricular approach for gap arthroplasty A clinical investigation Journal of Cranio - Maxillo -Facial Surgery 40 (2012) 500-505 3-Mar-17 52 3-5cm incision is made parallel & posterior to postauricular flexure Begins at superior aspect of external pinna and extended till the tip of mastoid process Dissection is done through posterior auricular muscle to the level of mastoid fascia

53. Transected auditory canal closure of auditory canal Final closure of the incision. 3-Mar-17 53

54. ADVANTAGES Predictability of anatomic exposure excellent surgical exposure of the bilaminar zone and the mandibular condyle posteriorly Cosmetic superiority Less risk of CN VII injury Dissection is more rapid DISADVANTAGES Not advised in patients susceptible to keloid I nfection Meatal stenosis can occur A nterior exposure is limited 3-Mar-17 54

55. Coronal approach or bicoronal / hemicoronal or bitemporal approach versatile surgical approach to the upper and middle regions of the facial skeleton, including the zygomatic arch and TMJ. major advantage of this approach is that most of the surgical scar is hidden within the hairline. 3-Mar-17 55

56. Layers of the scalp above the superior temporal line 3-Mar-17 56 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

57. 3-Mar-17 57 LAYERS OF THE SCALP BELOW THE SUPERIOR TEMPORAL LINE Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

58. 3-Mar-17 58 Incision placement for patients with male pattern hair recession. The incision is stepped posteriorly just above the attachment of the helix of the ear Incision placement for most female patients. The incision is kept approximately 4 cm behind the hairline Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

59. S cratches, or tattoo dye markings are made across the proposed site of incision. The first marking is made in the midline and subsequent marks are made laterally at approximately equal distances from the midline. 3-Mar-17 59 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

60. T he incision is through the skin, subcutaneous tissue, and galea revealing the subgaleal plane of loose areolar connective tissue overlying the pericranium 3-Mar-17 60 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

61. 3-Mar-17 61 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

62. 3-Mar-17 62 The skin incision below the superior temporal line should extend to the depth of the glistening superficial layer of the temporalis fascia , into the subgaleal plane, continuous with the dissection above the superior temporal line. Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

63. 3-Mar-17 63 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed Along the lateral aspect of the skull, the glistening white temporalis fascia becomes visible where it blends with the pericranium at the superior temporal line . The plane of dissection is just superficial to this thick fascial sheet

64. 3-Mar-17 64 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed Near the ear, the flap is dissected inferiorly to the root of the zygomatic arch by incising superficial layer of temporalis fascia The lateral portion of the flap is dissected inferiorly atop the temporalis fascia

65. Exposure of the Temporomandibular Joint : Access to the TMJ region is gained by dissecting below the zygomatic arch anterior to tragal cartilage. Masseter is detached from the zygomatic arch exposing the sigmoid notch and TMJ capsule. Capsule is then incised exposing the TMJ. 3-Mar-17 65

66. CLOSURE : done in layers Closure of TMJ capsule is done followed by closure of temporalis fascia . Superficial layer of the temporalis fascia, which is incised during the approach , is sutured approximately 1 cm superior to the superior edge of the incised fascia. Galea is closed as a distinct layer. Scalp incision is closed. 3-Mar-17 66

67. 3-Mar-17 67 The coronal incision has been modified. The principal difference involves the position of the skin incision – placed behind the ear. use of a zigzag incision instead of a straight incision within the hairline. AD: further camouflage of the scar

68. SUBMANDIBULAR or Risdon’s APPROACH 3-Mar-17 68

69. 3-Mar-17 69 Incision usually starts 1.5-2cm inferior to the lower border of mandible. The initial incision is carried through the skin and subcutaneous tissues to the level of the platysma muscle. Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

70. 3-Mar-17 70 Dissection of platysma and exposure of superficial layer of deep cervical fascia Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

71. dissection to the pterygomasseteric muscular sling 3-Mar-17 71 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

72. 3-Mar-17 72 Associated anatomic structures Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

73. dissection is performed through the fascia at the level of the initial skin incision, followed by dissection superiorly to the level of the periosteum of the mandible 3-Mar-17 73

74. 3-Mar-17 74 With retraction of the dissected tissues, the inferior border of the mandible is seen. The pterygomasseteric sling is sharply incised with a scalpel along the inferior border Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

75. 3-Mar-17 75 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

76. closure is done in multiple layers - the masseter and medial pterygoid muscles are sutured together platysma muscle is closed subcutaneous tissues and skin closure is done 3-Mar-17 76 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

77. Extended submandibular approach 3-Mar-17 77

78. RETROMANDIBULAR APPROACH or hind’s approach exposes the entire ramus from behind the posterior border . therefore may be useful for procedures involving the area on or near the Condylar neck/head , or the ramus itself 3-Mar-17 78 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

79. ADVANTAGES: close proximity to the condylar area DISADVANTAGES: passing through the parotid gland tissue, thus increasing the risk of facial nerve injury and salivary fistulae. 3-Mar-17 79

80. Important structures encountered 3-Mar-17 80 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

81. Draping: main landmarks should be visible – ear, lower lip and corner of mouth INCISION: begins 0.5cm below the ear lobe continues inferiorly 3-3.5cm just behind the posterior border of mandible. 3-Mar-17 81 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

82. 3-Mar-17 82 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

83. 3-Mar-17 83 Blunt dissection Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

84. 3-Mar-17 84 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

85. 3-Mar-17 85 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

86. closure 3-Mar-17 86 Approximating pterygomasseteric sling Closure of parotid capsule Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

87. Transmasseter Approach to Condylar Fractures by Mini-Retromandibular Access J Oral Maxillofac Surg 67:2418-2424, 2009 3-Mar-17 87

88. advantage Smaller scar as access was limited to 2cm only. Plane of dissection was superficial to SMAS. Risk of Frey’s syndrome, sialocoele and salivary fistula can be eliminated. Surgical site is always perpendicular to fracture site. Integrity of joint is always maintained. 3-Mar-17 88

89. Novel Retromandibular Subparotideomasseteric Fascial Approach for Placement of a Temporomandibular Joint Prosthesis J Oral Maxillofac Surg 72:1266.e1-1266.e5, 2014 3-Mar-17 89

90. Modified blair incision 3-Mar-17 90

91. 3-Mar-17 91

92. rhytidectomy Also called as facelift approach. Variant of retromandibular, transmasseteric - anteroparotid approach 3-Mar-17 92

93. Landmarks for draping When using the rhytidectomy approach, the structures that should be visible in the field include – the corner of the eye , the corner of the mouth , and the lower lip anteriorly, the entire ear and descending hairline, and 2 to 3 cm of hair superior to the posterior hairline, posteriorly the temporal area must also be completely exposed superiorly 3-Mar-17 93

94. The incision begins approximately 1.5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the hairline. The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna. The incision continues under the earlobe and approximately 3 mm onto the posterior surface of the auricle instead of continuing in the mastoid–ear skin crease. I t curves posteriorly toward the hairline and then runs along the hairline, or just inside it, for a few centimeters. 3-Mar-17 94 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

95. 3-Mar-17 95 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

96. 3-Mar-17 96 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

97. 3-Mar-17 97 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

98. closure 3-Mar-17 98 Surgical approaches to facial skeleton – Edward Ellis 2 nd ed

99. Transoral /intraoral access 3-Mar-17 99

100. 3-Mar-17 100 Gap arthroplasty for temporomandibular joint ankyloses by transoral approach: A case series Int. J. Oral Maxillofac Surg

101. Endoscope Through intraoral incision 3-Mar-17 101 AD: better visibility access to high level fracture using transbuccal trocar.

102. Once the capsule has been identified, access to the articular surfaces (superior and inferior joint spaces) can be obtained by a great variety of incisions. 3-Mar-17 102 Capsular incisions

103. ; 3-Mar-17 103 horizontal incision over the lateral rim of the glenoid fossa The lateral ligament, capsule, and periosteum are reflected inferiorly en masse. Discal or posterior attachment are dissected sharply with scissors to the level of the condylar neck . Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

104. 3-Mar-17 104 The posterior attachment and disc attachments are then severed sharply at the lateral pole of the condyle from within the developed flap. These tissues are then reflected superiorly from the head of condyle to expose inferior joint space Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

105. horizontal incision below the lateral rim of the glenoid fossa 3-Mar-17 105 The superior joint space is punctured at the level of discocapsular sulcus. A dissection is then carried inferiorly removing the attachment of the capsule to the disc and exposing the inferior joint space. Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

106. HORIZONTAL INCISIONS ABOVE AND BELOW THE DISC 3-Mar-17 106 Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

107. T-SHAPED INCISION 3-Mar-17 107 Peterson’s Principles of Oral and Maxillofacial Surgery – 3 rd ed

108. complications Poor facial scar Infection Wound dehiscence Facial nerve palsy Perichondritis Sialocoele Frey’s syndrome 3-Mar-17 108

109. Poor facial scar 3-Mar-17 109

110. Facial nerve paralysis 3-Mar-17 110

111. perichondritis 3-Mar-17 111 SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration

112. MANAGEMENT: Conservative: mildest form is treated by using oral and topical antibiotics. Hematoma of the auricle should be drained properly If there is any sign of pus drainage – C/S followed by broad spectrum IV antibiotics. In resistant cases, continuous drainage and irrigation with antibiotics and steroids solution. In severe cases, aggressive excision of the necrosed cartilage involving overlying subcutaneous tissues and skin should be done. 3-Mar-17 112

113. Sialocoele /salivary fistula 3-Mar-17 113 Sialocoeles result in the accumulation of saliva in glandular/ periglandular or subcutaneous tissues. When the accumulated saliva drain through the skin it is termed as salivary fistula.

114. MANAGEMENT Small sialocoeles have said to resolve spontaneously by scar formation which seals the salivary flow. Non surgical management: repeated aspirations and compression dressings administration of anticholinergics antisialogogues 3-Mar-17 114

115. Surgical management : These procedures direct the salivary flow into the mouth or Depresses the salivary secretion Creating a tract intraorally Duct ligation Sectioning of auriculotemporal nerve Surgical excision of fistulous tract 3-Mar-17 115

116. frey’s syndrome 3-Mar-17 116 J Oral Maxillolac Surg49:680-682 . 1991 named after Dr. Lucia Fre y Frey’s syndrome or gustatory sweating and flushing is characterized by sweating and flushing of the facial skin during meals. The area involved is on the lateral aspect of the face and upper neck, usually around the parotid region.

117. 3-Mar-17 117 Minor starch iodine test The distribution of the greater auricular nerve and ATN was painted with a solution containing 3 g iodine, 20 g castor oil, and 200 mL of absolute alcohol. When dry, the area was lightly dusted with cornstarch . Given lemon drops to chew for 4 minutes to induce a salivary response. A positive test occurs when sweat dissolves the starch powder and it reacts with the iodine to produce dark blue spots that may become confluent

118. Techniques to evaluate - Blotting paper method Iodine sublimated paper histogram Treatment: external radiotherapy local or systemic application of anticholinergic drugs Laage -Hellman was the first to apply scopolamine (3% cream) for the treatment of gustatory sweating. interposition of a subcutaneous barrier injection of botulinum toxin in the involved skin 3-Mar-17 118

119. Section of some portion of the efferent neural arc Hemenway [62] in 1960 suggested interrupting the efferent neuronal pathway at the level of the middle ear, by sectioning the tympanic nerve of Jacobson. The first such procedure for gustatory sweating was carried out by Golding-Wood , who named it “tympanic neurectomy 3-Mar-17 119

120. Surgical Interposition the use of a barrier between the facial skin and the parotid bed. Botulinum Toxin The injection of botulinum A toxin in the skin involved by gustatory sweating was recently proposed by Drobik and Laskawi . It acts by blocking the exocytosis mechanism of the presynaptic terminal, thereby inhibiting release of acetylcholine. 3-Mar-17 120

121. Know your anatomy properly. - Emphasis on Facial .N relation to fascial layers. Importance of maintaining proper dissection plane. Chose the appropriate approach based on the problem. Be aware of the possible complications from each of the approach.