Internal Derangement of TMJ

International Journal of Advances in Health Sciences (IJHS)
ISSN 2349-7033
Vol2, Issue5, 2015, pp654-664
http://www.ijhsonline.com
Review Article
Internal Derangement of TMJ
Muralee Mohan, B. Rajendra Prasad,
Tripthi Shetty and Prabhakar Gupta
Oral and axillofacial Surgery,A.B.S.M.I.D.S., Karnataka, India
[Received-09/10/2015, Accepted-17/10/2015, Published- 27/10/2015]
ABSTRACT:
Internal derangement of temporomandibular joint can be defined asAnteriomedial displacement of disc, associated
posteriosuperior displacement of condyle in the closed jaw position.Temporomandibular joint (TMJ) is a sensitive,
complex and highly mobile joint. Temporomandibular disorders (TMD) are a class of degenerative musculoskeletal
conditions associated with morphologic and functional deformities that affect up to 25% of the population. The most
frequent structural (as opposed to muscular) cause of TMD are the Internal derangement , that involves progressive
slipping a displacement of component of temporomandibular joint called articular disc. Because the deranged joint
willcontinue to try to function in an impaired manner, so that internal derangement disorder often get progressively
worse with time. In the mechanically demanding and biochemically active environment of the TMJ, therapeutic
conservative and surgical approaches that can restore joint functionality while responding to changes in the joint
have become a necessity.
Keywords: Temporomandibular joint (TMJ), Temporomandibular jointdisorder (TMD).
INTRODUCTION:
Internal derangement is defined as any
interference
with
smooth
joint
1
movement. Although the term therefore includes
all types of intracapsular interferences that
impede smooth functional joint movements, with
regard to the temporomandibular joint (TMJ).
The term is typically used interchangeably with
disc displacement.
Temporomandibular joint (TMJ) is a unique joint
in which translational as well as rotational
movements are possible and where both the ends
of bones articulate, in same plane, with that of
other bone. The TMJs are bilateral, diarthroidial,
ginglymoid, synovial, and freely movable.The
term diarthrodial is used because the joint has
two
articulating
bone
components—the
mandibular condyle inferiorly, and the articular
eminence and glenoid fossa of the temporal bone
superiorly. The term ginglymoid is used because
the joint has a hinge like movement component.
The joint is lined by synovial membrane, and it is
freely movable.2 The unique features of TMJ
includes (1) The articulating surfaces are covered
not by hyaline cartilage but by fibro elastic
tissue; (2) The condylar cartilage is considered a
growth centre that insignificantly contributes to
the overall growth of the mandible but is
important for condylar response to trauma. (3)
The TMJ functions bilaterally and can be
influenced by dental occlusion; (4) The TMJ has
an intact disk that is movable during all joint
movements and functions as a shock absorber.3
Myofascial pain disorders are the most common
cause of pain in the head and neck, and those
involved in the temporomandibular joint are no
exception.4 Joint disorders are the second most
common cause of persistent head and neck pain.
Included are internal derangements, degenerative
joint disease and inflammation of the joint space
(capsulitis).4
Dislocation of the jaw is either acute or chronic.
An acute dislocation results when the mandible is
fixed in an open position with only the posterior
teeth in contact. Chronic recurrent dislocation is
usually due to abnormally lax ligaments.4The
most common TMJ arthropathy is the internal
derangement, which is characterized by a
progressive anterior disc displacement. It is often
associated with a capsulitis, making pain a
common feature. On physical exam, a popping is
felt and heard, with associated pain. It involves
progressive slipping or displacement of a
component of the temporomandibular joint called
the articular disc.
Clinical anatomy and physiology of TMJ:
The temporomandibular joint (TMJ) is composed
of the temporal bone and the mandible, as well as
a specialized dense fibrous structure, the articular
disk, several ligaments, and numerous associated
muscles. It is a compound joint that can be
classified by anatomic type as well as by
function. Anatomically the TMJ is a diarthrodial
joint, which is a discontinuous articulation of two
bones permitting freedom of movement that is
dictated by associated muscles and limited by
ligaments.Functionally the TMJ is a compound
joint, composed of four articulating surfaces: the
articular facets of the temporal bone and of the
mandibular condyle and the superior and inferior
surfaces of the articular disk.Articular disk
divides the joint into two compartments. The
Prabhakar Gupta, et al.
lower compartment permits hinge motion or
rotation and hence is termed ginglymoid. The
superior compartment permits sliding (or
translatory) movements and is therefore called
arthrodial. Hence the temporomandibular joint as
a whole can be termed ginglymoarthrodial.5
Bony Structures:
The articular portion of the temporal bone (Fig. –
1,2,3) is composed of three parts. The largest is
the articular or mandibular fossa, a concave
structure extending from the posterior slope of
the articular eminence to the postglenoid process,
which is a ridge between the fossa and the
external acoustic meatus. The surface of the
articular fossa is thin and may be translucent on a
dry skull.The second portion, the articular
eminence, is a transverse bony prominence that
is continuous across the articular surface
mediolaterally.The third portion of the articular
surface of the temporal bone is the preglenoid
plane, a flattened area anterior to the eminence.
The mandible is a U-shaped bone that articulates
with the temporal bone by means of the articular
surface of its condyles, paired structures forming
an approximately 145° to 160° angle to each
other.On its medial aspect just below its articular
surface is a prominent depression, the pterygoid
fovea, which is the site of attachments of the
lateral pterygoid muscle.5
Fig.1.The left temporomandibular joint viewed from
the sagittal aspect on a dry skull.
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Fig. 2.The left temporomandibular joint viewed from
the oblique/coronal aspect on a dry skull.3
Fig. 3. The left glenoid fossa and articular eminence.6
The component of TMJ are presented in
following sequence: capsule, extracapsular
ligament, articular eminence, glenoid fossa,
condyle, disk, disk ligament, and synovial
membrane.3
Capsule:
The joint capsule is a fibroelastic, highly
vascular, and highly innervated dense connective
tissue.
The lateral aspect of capsule attaches to the
zygomatic tubercle, the lateral rim of glenoid
Prabhakar Gupta, et al.
fossa, and the postglenoid tubercle.The lateral
capsule continues medially until the midsagittal
plane and then become less distinct anteriorly at
the site where superior and inferior heads of
lateral pterygoids supports the anterior bilaminar
zone. Medially, the capsule attaches to medial
rim of glenoid fossa.
The spine of sphenoid, the sphenomandibular
ligament, and the middle meningeal artery
passing through the foramen spinosum are all
closely related to medial capsule. Posteriorly, the
capsule attaches to petrotympanic fissure and
fuses with the superior stratum of posterior
bilaminar zone.6Enlargement of the parotid could
impinge on the posterior capsule of the TMJ and
cause pain during chewing movements. The
lateral capsule is thought to be thickened to form
a definite ligament known as temporomandibular
ligament.3, 6
Extracapsular Ligaments:
The main extracapsular ligaments that provide
stability to the joint are the lateral
temporomandibular
and
sphenomandibular
ligaments. The sphenomandibular ligament
originates from the anterior process of the
malleus, the lips of petrotympanic fissure, and
the sphenoid above and insert into the lingual of
the mandibular foramen below.
At its upper end, the ligament is crossed by the
chorda tympani nerve. The ligament represents
one of the embryonic remnants of Meckel’s
cartilage.Loughner and colleagues7 found, that
the sphenomandibular ligament has no
connection to the medial capsule of the TMJ and
therefore has no significance to the biomechanics
of the joint.
The stylomandibular ligament attaches to the
styloid process above and the angle and posterior
border of the mandibular ramus below. The
pterygomandibularraphe, when present, attaches
to the pterygoidhamulus above and to the
posterior end of the mylohyoid ridge of the
mandible below.3, 7
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Articular eminence:
The glenoid, or mandibular, fossa is limited
posteriorly by the boundary of the posterior
superior recess of the joint cavity. The fossa has
lateral and medial rims. The medial rim is just
lateral to spine of the sphenoid and the foramen
spinosum with its middle maningeal artery. The
lateral rim continues anteriorly into the
zygomatic tubercle, which can be felt under the
skin, and posteriorly into postglenoid
tubercle.The fossa is covered by a thin fibrous
layer, suggesting that the area is not normally
loaded.3
Condyle:
The condyle is broad mediolaterally and narrow
anteroposteriorly. It has a lateral tubercle that can
be felt under the skin, a joint capsule and, a
medial tubercle.
The tubercle provides attachments to the lateral
and medial collateral ligaments. The condylar
axis runs between the tubercles in a
posteromedial direction and meet the axis from
apposite site at an angle which varies from zero
to obtuse.
The articular surface of condyle is covered by a
thick layer of fibroelastic tissue containing
fibroblast and a variable number of
chondrocytes.At a young age, the deepest layer
of fibrocartilage is rich in small undifferentiated
cell; this is called as the reserve cell layer.7
Disk:
The disk fills the space between the condyle and
temporal bone. In the centric relation position of
the mandible, the central portion of the disk is in
contact superiorly with the descending slop of
the articular eminence and inferiorly with the
convex articular surface of the condyle.
Therefore, the disk is biconcave in shape, with
anterior and posterior rims and medial and lateral
rims. Anatomically the disk can be divided into
three general regions as viewed from the lateral
Prabhakar Gupta, et al.
perspective: the anterior band, the central
intermediate zone, and the posterior band.
Ligaments:
Ligaments associated with the TMJ are
composed of collagen and act predominantly as
restraints to motion of the condyle and the disk.
Three ligaments—collateral, capsular, and
temporomandibular ligaments— are considered
functional ligaments because they serve as major
anatomic components of the joints. Two other
ligaments
sphenomandibular
and
stylomandibular— are considered accessory
ligaments because, although they are attached to
osseous structures at some distance from the
joints, they serve to some degree as passive
restraints on mandibular motion.5
Musculature related to TMJ:
All muscles attached to the mandible influence
its movement to some degree. Only the four large
muscles that attach to the ramus of the mandible
are considered the muscles of mastication;
however, a total of 12 muscles actually influence
mandibular motion, all of which are
bilateral.5Muscle pairs may function together for
symmetric movements or unilaterally for
asymmetric movement. For example, contraction
of both lateral pterygoid muscles results in
protrusion and depression of the mandible
without deviation, whereas contraction of one of
the lateral pterygoid muscles results in protrusion
and opening with deviation to the opposite side.
Innervation of the TMJ:
The TMJ receives innervations primarily from
auriculotemporal nerve branch of the mandibular
nerve, with contribution from other branches
from V3, such as the masseteric and deep
temporal nerves. The joint capsule, the disk
ligaments (anterior, posterior, medial, and
lateral), and the synovium are innervated,
whereas disk proper and the fibrous coverings of
the articulating surfaces and condylar cartilages
657
are non-innervated. In addition to the nerve
fibres, the TMJ capsules contains three type of
mechanoreceptors: Ruffini receptors, Golgi
tendon organs, and pacinian corpuscles.8 The use
of nerve specific antibodies such as
neurofilaments and myelin basic proteins
confirmed the absence of nerves in disk proper,
the condylar cartilage, and the fibrous coverings
of the articulating surfaces and confirmed the
presence of nerves in in the disk attachments and
the capsule.3,8
Radiographic anatomy of TMJ:
A thorough understanding of the anatomy and
morphology of the TMJ is essential so that a
normal variant is not mistaken for an
abnormality. The TMJs are unique in that in that
although they constitute two separate joints
anatomically, they functions together as a single
unit.The condyle is a bony, ellipsoid structure
connected to the mandibular ramus by a narrow
neck (Fig. 4). The condyle is approximately
20mm long mediolaterally and 8-10 mm thick
anteroposteriorly.
The shape of condyle varies considerably; the
superior aspect may be flattened, rounded, or
markedly convex, whereas the mediolateral
contour usually is slightly convex. These
variations in shape may cause difficulty with
radiographic interpretation; this underlines the
importance of understanding the range of normal
appearance. The extreme aspects of the condyle
are called medial pole and lateral poles.The long
axis of the condyle is slightly rotated on the
condylar neck such that the medial pole is angled
posteriorly, forming an angle of 15 to 33 degrees
with the sagittal plane. The two condylar axes
typically intersect near the anterior border of the
foramen magnum in the submentovertex
projection.9Although the mandibular and
temporal components of the TMJ are calcified by
6 months of age, complete calcification of
cortical borders may not be completed until 20
years of age. As a result, radiographs of condyles
Prabhakar Gupta, et al.
in children may show little or no evidence of a
cortical border.
Mandibular fossa:
The glenoid (mandibular) fossa is located at the
inferior aspect of the squamous part of the
temporal bone and is composed of the glenoid
fossa and articular eminence of the temporal
bone. It is sometimes described as the temporal
component of TMJ. The articular eminence
forms the anterior limit of the glenoid fossa and
is convex in shape. It’s most inferior aspect is
called summit or apex of the eminence.In a
normal TMJ, the roof of the fossa, the posterior
slope of the articular eminence and eminence
itself form an S shape when viewed in the
sagittal plane.
Interarticular disk:
The interarticular disk (meniscus), composed of
fibrous connective tissue, is located between the
condylar head and mandibular fossa. The disk
divides the joint cavity into two compartments,
called the inferior (lower) and superior (upper)
joint spaces, which are located below and above
the disk respectively.
Posterior attachment (Retrodiskal tissue):
The posterior attachment consists of a bilaminar
zone of vascularized and innervated loose
658
fibroelastic tissue. The superior lamina, which is
elastin, inserts into the posterior wall of the
mandibular fossa. The superior lamina stretches
and allows the disk to move forward with
condylar translation.The inferior lamina attaches
to the posterior surface of the condyle. The
posterior attachment is covered with a synovial
membrane that secretes synovial fluid, which
lubricates the joint. As the condyle moves
forward, tissue of the posterior attachment
expand in volume, primarily as a result of venous
distention, and as the disk moves forward,
tension is produced in the elastic posterior
attachment. This tension is thought to be
responsible for the smooth recoil of the disk
posteriorly as the mandible closes.9
Definitions:
Internal derangement of temporomandibular joint
can be defined in at least three different ways:
1. Anteriomedial displacement of disc, associated
posteriosuperior displacement of condyle in the
closed jaw position.10 By David A Keith
2. Dysfunctional centric relation.10 By David A
Keith
3. A disturbance in normal anatomic relationship
between the disc and condyle that interferes with
smooth movement of the joint and causes
momentary catching, clicking, popping, or
locking.3 By Reymond J Fonseca
Definitions of various types of internal
derangements of the TMJ 1
Disc derangement- A malpositioning of the
articular disc relative to the condyle and
eminence.
Disc derangement with reduction- The
articular disc resumes its normal position on top
of the condyle on opening.
Disc derangement without reduction- The
articular disc remains malpositioned on opening
attempts, resulting in restricted mouth opening in
acute cases.
Prabhakar Gupta, et al.
Disc adherence - A temporary sticking of the
disc either to the fossa or to the condyle.
Disc adhesion - A fibrotic connection between
the disc and the condyle or the disc and the fossa.
Wilkes staging classification for internal
derangement of TMJ10
I. Early Stage
A. Clinical: no significant mechanical symptoms
other than early opening reciprocal clicking; no
pain or limitation of motion.
B. Radiologic: slight forward displacement; good
anatomic contour of the disk; negative
tomograms.
C. Anatomic/pathologic: excellent anatomic
form; slight anterior displacement; passive
incoordination demonstrable.
II. Early/Intermediate Stage
A. Clinical: one or more episodes of pain;
beginning major mechanical problems consisting
of mid- to late-opening loud clicking, transient
catching, and locking.
B. Radiologic: slight forward displacement;
beginning disk deformity of slight thickening of
posterior edge; negative tomograms.
C.
Anatomic/pathologic:
anterior
disk
displacement; early anatomic disk deformity;
good central articulating area.
III. Intermediate Stage
A. Clinical: multiple episodes of pain; major
mechanical symptoms consisting of locking
(intermittent or fully closed), restriction of
motion, and difficulty with function.
B. Radiologic: anterior disk displacement with
significant deformity/prolapse of disk (increased
thickening of posterior edge); negative
tomograms.
C. Anatomic/pathologic: marked anatomic disk
deformity with anterior displacement; no hard
tissue changes.
659
IV. Intermediate/Late Stage
A. Clinical: slight increase in severity over
intermediate stage
B. Radiologic: increase in severity over
intermediate stage; positive tomograms
showing early to moderate degenerative
changes—flattening of eminence; deformed
condylar head; sclerosis
C. Anatomic/pathologic: increase in severity
over intermediate stage; hard tissue degenerative
remodeling
of
both
bearing
surfaces
(osteophytosis); multiple adhesions in anterior
and posterior recesses; no perforation of disk or
attachments.
V. Late Stage
A. Clinical: crepitus; scraping, grating, grinding
symptoms; episodic or continuous pain; chronic
restriction of motion; difficulty with function
B. Radiologic: disk or attachment perforation;
filling defects; gross anatomic deformity of disk
and hard tissues; positive tomograms with
essentially degenerative arthritic changes
C. Anatomic/pathologic: gross degenerative
changes of disk and hard tissues; perforation of
posterior attachment; multiple adhesions;
osteophytosis; flattening of condyle and
eminence; subcortical cystic formation.
ETIOLOGY:
The most common etiologic factor in the
development of internal derangements is trauma.
Macrotrauma, such as hit or blow on the face,
may result in direct tissue injury and immediate
derangements of TMJ components.Microtrauma
may be another etiologic factor in the
development
of
internal
derangements.
Microtrauma is defined as application of
prolonged repetitive forces, such as in clenching
or grinding. The repetitive forces may result in
tissue failure in several ways. When the force is
within physiologic limits, but is applied to
articular cartilage that has a reduced adaptive
capability, or when the force exceeds the
Prabhakar Gupta, et al.
adaptive capability of normal cartilage, tissue
degeneration may ensue.1
Management of internal derangement of
TMJ:
Perioperative Management
If a patient has documented Internal
derangement, every attempt should be made to
reduce the disk nonsurgically or relieve pain via
medical, physical, or palliative measures. This
may include soft diet, NSAIDs, occlusal splints,
mandibular manipulations, or a combination of
well-known nonsurgical methods.5,11 After all
preoperative, nonsurgical methods have been
exhausted and the patient is being managed with
the most comfortable combination of splints and
other modalities, the referring dental practitioner
constructs a centric splint for the purpose of
managing postoperative proper cure. In some
cases, this may be the splint that the patient has
been wearing during the preoperative attempts to
alleviate pain.5,11
Postoperative:
Surgery on the TMJs usually results in some
temporary alteration in the occlusion; the patient
should be seen by the splint therapist within 1 to
2 days postoperatively for a splint adjustment.
Commonly, there is a posterior open bite on the
side that surgeries was done, or bilaterally if the
surgery was double sided. In either case the
posterior splint is built up to match the new
occlusion, with the realization that this is only a
temporary and will change over the next 6 to 8
weeks. The patient is then seen again at 1, 3, and
6
weeks
postoperatively
for
splint
adjustments.Also,
with
opening
against
resistance exercises most patients will approach
their normal opening within the 8- week
period.3,11
Nonsurgical Therapy:
Diet:
A soft diet is often overlooked in the
management of TMD. A soft diet prevents
660
overloading of the TMJ and decreases muscle
activity that may be hyperactive.Strict liquid diet
is reserved for those patients experiencing severe
TMD symptoms.1,5
Pharmacotherapy:
Medications are often prescribed for managing
the symptoms associated with TMD. Patients
should understand that these medications may
not offer the cure to their problem but can be a
valuable adjunctive aid when prescribed as part
of
a
comprehensive
program.
With
pharmacotherapy there is always a danger of
drug dependency and abuse, particularly with
narcotics and tranquilizers.The most common
pharmacologic agents used for the management
of TMD are analgesics, anti-inflammatory
agents, anxiolytic agents, antidepressants, muscle
relaxants, antihistamines, and local anesthetics.
Physical Therapy:
There are many factors contributing to limited
range of motion. They include muscular pain,
anterior disk displacement (closed lock), and
fibrotic scar tissue preventing rotation or
translational movements. It is well accepted that
immobilization has deleterious effects on both
joints and muscles.
Exercise Therapy
Physical therapy and exercise are an important
part of any TMD program. Mild or acute
symptoms can be initially managed with soft
diet, jaw rest, heat/ice packs, jaw/tongue posture
opening exercises, lateral jaw movements, and
passive stretching exercises. Once again the
exact sequence of therapy is unknown but is
usually based on degree of pain and limitation of
function. Further reduction of pain and
inflammation may require an office-based
physical therapy program. Ultrasonography,
transcutaneous electrical nerve stimulation
(TENS), soft tissue manipulation, trigger point
injections, and acupuncture have also been
Prabhakar Gupta, et al.
advocated as effective in the management of the
TMD patient.5
Active exercise using the patient’s jaw
musculature may be incorporated into a home
therapy program. One regimen allows the patient
to activate, for example, their suprahyoid
muscles (Geniohyoid, mylohyoid, digastric, and
stylohyoid), thereby inactivating the elevators of
the jaw (Medial Pterygoid, masseter, temporalis).
This may allow for relaxation of hyperactive
muscles of mastication and may assist in
increasing maximal incisal opening.Kurita and
colleagues described a technique of placing one
thumb on the last molar on the affected side
while the other hand supports the head in the
temporal region.12 Yuasa and Kurita suggested
that physical therapy along with administration
of NSAIDs (for a 4-week period) is a more
effective way to treat TMJ disk displacement
without osseous changes None the less, there is
no shortage of recommended exercises, and care
must be taken to do no harm of the patients
received
significant
benefit
from
the
manipulation, and the more advanced the
displacement, the less the success of the
treatment.5,12
Thermal Agents
Thermal agents are often incorporated in the
management of TMD. The use of cold and heat
can alleviate muscle pain and play an equal role
during stretching and strengthening exercises.
Heat therapy has been reported to reduce muscle
pain by increasing nerve conduction velocity and
local vasodilatation. Superficial heat therapy can
be implemented with conductive (hot packs,
paraffin, whirlpool) or radiant (infrared) agents.
The most common types used are a moist hot
wash cloth, heating pad, or hydro collator, a pad
filled with clay and heated in a water bath to 70°
to 88°C. It is wrapped in a towel and placed on
the site for 15 to 20 minutes, causing a transient
rise in skin temperature to about 42°C. The use
of moist heating pads is an effective modality of
661
treatment for myofacial pain associated with
TMD.5,11 Cryotherapy is often used as an aid in
stretching muscles in an attempt to increase
maximal incisor opening limited by pain.
type of splints (i.e. pivotal splint, mandibular
anterior positioning appliance)(fig.5, 6) the
condyle disk glenoid fossa relationship is
―unloaded.12
Ultrasonograpy and Phonophoresis
Deep heat can be delivered by ultrasonography
or phonophoresis.The ultrasound machine is
applied to the skin along with an acoustic
conductive gel, and then moved slowly over the
affected area in small circular movements. The
operator must be careful not to keep the machine
in one place for too long as it may cause
overheating of the connective tissue, causing
structural damage. The deep heat is intended to
increase perfusion to the area, decreasing pain
and increasing mobility.The beneficial effects to
joints are reduced capsular contracture, break up
of calcium deposits, and decreasing hyaluronic
acid viscosity.13Because ultrasonography delivers
heat to the deeper structures, it may have some
advantage in treating tendonitis, capsulitis,
muscle spasm, and tight ligaments.5,13
Fig. 5 A pivot splint.2
Splint therapy
Rationale
Splint therapy has been reported to be effective
in pain management of patients with
intracapsular TMJ disorders including treatment
of disc displacements and temporomandibular
joint arthritis. Splints in the treatment of disk
disorders, including anteriorly displaced disks
with reduction and without reduction, are thought
to recapture and reposition the disk physically to
acorrected position above the condylar head.
Long term outcomes of repositioning splint
therapy are not as promising as once theorized.
Clinician have theorize that mechanically
altering the position of the mandible have 2
results: The first is that the condylar head being
held in a more inferior, anterior position will
mechanically persuade the disk to establish itself
atop the condylar head in a more favorable
position.14 The second is that in wearing certain
Prabhakar Gupta, et al.
Fig. 6 Mandibular anterior repositioning appliance.2
Occlusal Adjustment
There is a limited role for occlusal adjustment or
selective grinding in the treatment of TMD. The
purpose of selectively grinding the teeth is to
permanently position the dentition into a better
occlusion. It is an irreversible process and is best
suited for the acute TMD symptoms arising from
overcontoured restorations or post orthognathic
surgery. In these select cases the occlusal
equilibration allows for proper condylar
positioning and prevents muscular problems
associated with improper interferences.5
Surgical Procedures:
Many techniques have been suggested for the
treatment of ID. It is generally accepted that
Annandale in 1887 was the first to describe
surgery for the correction of internal
662
derangement10 although it is said that the Aztecs
may have used thorns to perform arthrocentesis
as long as 500 years ago. Since that time, many
surgical procedures have been elaborated,
without a distinct winner, these include:3
1. Arthrocentesis and lavage.
2. Arthroscopy.
3. Arthrotomy with disk repair.
A. Placation.
B. Bilaminar flap repair.
4. Arthorotomy with diskectomy.
5. Arthorotomy with diskectomy and autologous
graft disk replacements.
6. Arthrotomy with diskectomy and autologous
flap reconstruction.
7. Arthrotomy with diskectomy and alloplastic
disk replacement.
8. Condylotomy.
Complications:
Complications
may
arise
immediately
(intraoperatively or within 24 hr) or be delayed
(> 24 hr). Transient neuropraxia of the temporal
branches of the facial nerve occurs in as many as
20 to 30% of cases. Typically, the injury is of
little significance to the patient and resolves
within 3 to 6 months. The incidence increases
when a separate skin flap is raised.Injury to the
chorda tympani from aggressive condylar
retraction in the medial aspect of the fossa may
occur rarely as well. Neuropraxia of the inferior
alveolar and, less commonly, the lingual nerves
may result from clamp placement for joint
manipulation.
Auriculotemporal
syndrome
(gustatory sweating, Frey’s syndrome) has been
reported as a result of the dissection of the joint.3
Hemorrhage from the retrodiskal tissue may
interfere with performance of the disk repair.
Temporary control may be obtained with seating
of the condyle in the glenoid fossa.
Electrocautery, injection of epinephrine, or
application of hemostatic agents while
maintaining the mandible in the closed position
may be necessary.5
Prabhakar Gupta, et al.
Summary:
TMJ internal disc derangements most often
respond well to nonsurgical methods. An
asymptomatic click does not warrant treatment.
In line with the Clinical Practice Guidelines for
TMJ Surgery, surgical options should only be
used in cases of moderate to severe persistent
pain
or
dysfunction,
after
reasonable
conservative treatment has proven in effective.
Possible exceptions are acute disc adherences,
and adhesions, in which surgical methods, such
as arthrocentesis and arthroscopy, may be the
first treatment of choice. For disc derangements,
a multitude of surgical procedures are available,
but recent advances in technology and
philosophy direct the surgical procedures of
choice toward the minimally invasive technique,
arthrocentesis, with arthroscopy as the next
alternative.
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