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Oral Surgery 2 > Surgery for Temporomandibular Joint Disorders > Flashcards

Surgery for Temporomandibular Joint Disorders Flashcards

1
Q

TMD includes what?

A

joint and related extraarticular disorders

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2
Q

T/F: TMJ is a diagnosis or disease

A

false, is NOT

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3
Q

orthopedic principles of TMD

A
  1. lubrication
  2. nutrition
  3. joint stability
  4. loading
  5. articular ligaments
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4
Q

rotational movement of TMJ

A

20 mm

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5
Q

translational movement of TMJ

A

40-50 mm

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6
Q

lateral excursions move contralateral joint

A

7-10 mm

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7
Q

what movement translates both joints?

A

protrustion

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8
Q

what type of patients benefits from TMJ surgery?

A

patients…

  1. with mechanical or inflammatory joint disease
  2. who have failed nonsurgical therapy
  3. in whom muscle disorders are not the only problem
  4. where invasive tx will correct a mechanical dysfunction or reduce persistent inflammation
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9
Q

what type of operation that is best used to tx TMD is determined by what?

A

diagnosis

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10
Q

T/F: treatment sequence for internal derangement is consistent among surgeons

A

true

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11
Q

operations to tx internal derangement

A
  1. arthrocentesis
  2. arthroscopy
  3. open surgery
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12
Q

open operations vary widely according to what?

A
  1. region
  2. patient-specific conditions
  3. background and experience of the surgeon
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13
Q

what are some minimally invasive procedures to tx TMD?

A
  1. arthrocentesis

2. arthroscopy

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14
Q

T/F: arthrocentesis and arthroscopy have comparable list of indications

A

true

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15
Q

what is the most common diagnosis to tx with arthrocentesis and arthroscopy?

A

internal derangement

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16
Q

why might one skip arthrocentesis?

A
  1. long duration of symptoms
  2. hx of failed steroid injection/arthrocentesis
  3. long hx of late, hard, painful pop
  4. unable to obtain MRI
  5. anticipated difficulty with arthrocentesis
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17
Q

what might make some patients be unable to obtain MRI?

A
  1. certain implants
  2. severe claustrophobia
  3. morbid obesity
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18
Q

why might some patients have anticipated difficulty with arthrocentesis?

A
  1. obesity

2. anxious but has anesthetic risk

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19
Q

indicatiosn for arthrocentesis

A
  1. acute closed lock
  2. acute trauma (hemarthrosis)
  3. capsulitis/synovitis
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20
Q

advantages of arthrocentesis

A
  1. minimally invasive
  2. fast, simple procedure - usually done in office
  3. doesn’t require general anesthetic
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21
Q

arthrocentesis is highly effective at what?

A
  1. increasing joint mobility

2. reducing pain

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22
Q

disadvantages of arthrocentesis

A
  1. indication not well established except for acute closed lock
  2. may not adequately release adhesions, etc.
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23
Q

arthrocentesis has limited success for what?

A

chronic or more severe conditions

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24
Q

indications for arthroscopy

A

pain and dysfunction with the following conditions:

  1. decreased condylar translation due to disk hypomobility
  2. anteriorly displaced disk with or without reduction
  3. closed lock
  4. traumatic injury
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25
advantages of arthroscopy
1. minimally invasive 2. outpatient procedure 3. rapid recovery 4. excellent success 5. low morbidity 6. allows for examination under anesthesia
26
what is the success rate of arthroscopy
80-95%
27
disadvantages of arthroscopy
1. advanced disease may not improve 2. disk unlikely to reposition 3. requires aggressive postoperative physical therapy and patient compliance
28
failure to tx TMD with arthroscopy usually requires what?
open surgery
29
although extremely rare, morbidity of arthroscopy includes what?
nerve or middle ear injury
30
steps for arthroscopy
1. walk cannula into joint 2. penetrate capsule: palpable pop 3. switch to blunt trocar 4. advance to contact articular eminence 5. remove trocar and insert camera 6. introduce egress cannula (18 ga needle) 7. apply gentle irrigation pressure 8. inspect joint systematically
31
approximately how far should you advance trocar before contacting articular eminence during arthroscopy?
25 mm
32
what is inspected during arthroscopy?
1. retrodiscal tissue 2. articular eminence and disk 3. base of eminence and disk 4. anterior joint space
33
findings of synovial pathology progresses through what?
1. hypertrophy 2. hyperemia 3. capillary dilation 4. microbleeding 5. granulation, fibrosis
34
findings of articular surface pathology progresses through what?
1. softening 2. vascularization 3. fibrillation 4. bone exposure
35
adhesion types of pathology
1. light, filmy 2. fibrous bands 3. pseudowall
36
types of disk pathology
1. neovascularization 2. fibrillation 3. perforation
37
when is lysis of light adhesions done?
in course of inspection
38
how to perform adhesion lysis of heavier bands, walls
1. use blunt trocar 2. sweeping motion lateral-medial 3. light contact with articular surface 4. reassess with arthroscope
39
what is rarely a concern when it comes to lavage of adhesion lesions?
quantity - typically 2-300 ml or more
40
recent evidence questions efficacy of any joint medication. there is no difference between what?
1. steroid 2. hyaluronate 3. no drug
41
what is a joint medication widely used in Europe?
hyaluronate (Synvisc) but is more expensive and no proven advantage
42
outcomes of arthroscopic lysis and lavage
1. improved range of motion 2. decreased pain 3. improved function (primarily measured by diet)
43
what is the success rate of arthroscopic lysis and lavage?
80-92%
44
what is rarely altered with arthroscopic lysis and lavage?
disk position
45
arthrotomy
incision into the joint
46
arthroplasty
repair, revision, and/or reconstruction of joint tissues (hard and soft)
47
meniscectomy = disectomy
removal of disk
48
advantages of surgical approach for POSTAURICULAR arthrotomy
1. scar is hidden behind ear | 2. excellent posterolateral exposure
49
disadvantages of surgical approach for POSTAURICULAR arthrotomy
1. may give limited anterior joint access 2. longer operating time 3. keloid formation problematic
50
surgical approach for POSTAURICULAR arthrotomy may cause a greater potential for what?
chondritis
51
surgical approach for POSTAURICULAR arthrotomy may result in what?
1. meatal atresia | 2. possible psoterior auricle paresthesia
52
advantages of surgical approach for ENDAURAL arthrotomy
1. access similar to preauricular | 2. improved aesthetics, scar is mostly hidden
53
disadvantages of surgical approach for ENDAURAL arthrotomy
1. greater potential for chondritis | 2. aesthetic compromise if tragal projection is lost (common)
54
advantages of surgical approach for PREAURICULAR arthrotomy
1. excellent access and exposure | 2. avoids incision of external auditory canal or meatus
55
disadvantages of surgical approach for PREAURICULAR arthrotomy
1. potential aesthetic compromise | 2. risk of 7th nerve injury
56
indications for disk repair/repositioning procedures
1. minimal disk displacement 2. otherwise generally healthy joint tissues 3. near-normal disk morphology
57
advantages of disk repair/repositioning procedures
1. preserve maximum "normal" anatomic structure 2. may restore disk position to normal 3. improve mandibular ROM 4. restore "ideal" mechanics of joint by repositioning disk
58
how might disk repair/repositioning procedures improve mandibular range of motion (ROM)?
by eliminating mechanical obstruction
59
disadvantages of disk repair/repositioning procedures
1. often does not change disk position | 2. pop or click may recur
60
graft materials used in meniscectomy (discectomy) with/without interpositional graft
1. dermis 2. temporal fascia 3. auricular cartilage
61
indications for meniscectomy (discectomy) with/without interpositional graft
1. severe degenerative changes in disk 2. disk beyond repair 3. severe interference with normal function (i.e. patient with late, hard, painful pop on mouth opening due to disk reduction)
62
advantage of meniscectomy (discectomy) with/without interpositional graft
very good success rate with or without replacement
63
disadvantages of meniscectomy (discectomy) with/without interpositional graft
1. malocclusion or failure uncommon but possible 2. replacement requires graft harvest 3. replacement may offer little benefit over meniscectomy without graft 4. alloplastic materials (artificial disks) not available
64
outcomes of meniscectomy (discectomy) with/without interpositional graft
1. improved range of motion 2. decreased pain 3. improved function
65
how is improved function measured after meniscectomy (discectomy) with/without interpositional graft procedure?
by diet
66
what is the success rate of meniscectomy (discectomy) with/without interpositional graft?
80-85%
67
T/F: after meniscectomy (discectomy) with/without interpositional graft, joint sounds are altered by often remain
true, pop/click usually eliminated
68
what is common after a patient undergoes meniscectomy (discectomy) with/without interpositional graft?
mild crepitus
69
failures of meniscectomy (discectomy) with/without interpositional graft become what?
challenging cases
70
joint reconstruction
autogenous grafting and total joint replacement
71
indications for costochondral (rib) grafting
1. reconstruction of joint in children 2. reconstruction of congenital or acquired deformity 3. fibrous or bony ankylosis
72
advantages of costochondral (rib) grafting
1. allows restoration of joint mobility 2. allows for restoration or posterior vertical height 3. replaces growth center in children
73
disadvantages of costochondral (rib) grafting
1. requires rib harvest, donor site morbidity 2. may not grow at proper rate in children 3. grafts are subject to ankylosis, decreased mobility
74
T/F: repeat costochondral (rib) grafting after failure is usually beneficial
false, isn't
75
indications for total joint replacement
1. severe degeneration, usually mostly of the condyle 2. recurrent fibrous or bony ankylosis 3. failure of other reconstructive procedure (e.g. costochondral graft)
76
what can cause severe degeneration of condyle?
1. foreign body giant cell rxn 2. rheumatoid arthritis 3. juvenile idiopathic arthritis 4. idiopathic condylar resorption
77
advantages of total joint replacement
1. allows reconstruction in severely damaged joints 2. avoids graft harvest 3. effective at restoring reasonable interincisal opening
78
disadvantages of total joint replacement
1. components have finite lifespan 2. may not improve pain 3. expensive 4. treatment of last resort
79
what is the current estimated lifespan of total joint replacement?
15 years
80
reconstruction alternatives
1. partial alloplastic reconstruction | 2. autogenous reconstruction
81
T/F: partial alloplastic reconstruction is commonly done
false, generally not done
82
what is the most common donor site for autogenous reconstruction?
costochondral graft
83
where are some other donor sites for autogenous reconstruction?
cranial bone
84
what is sometimes used for fossa reconstruction?
cranial bone
85
contemporary systems
1. patient-fitted TMJ reconstruction prosthesis (TMJ concepts) 2. biomet microfixation prosthesis
86
which contemporary system has "stock" components and isn't a custom CAD-CAM prosthesis?
biomet microfixation prosthesis
87
goals of TMJ reconstruction
1. restore and maintain jaw fxn 2. resotre and maintain facial symmetry 3. long-term skeletal and occlusal stability
88
secondary goal of TMJ reconstruction
alleviate pain
89
postoperative care after TMJ reconstruction
1. immediate mobility 2. soft diet 3. physical therapy when necessary
90
outcomes of TMJ reconstruction
1. improved ROM 2. decreased (NOT eliminated) pain 3. improved diet
91
what percent of patients who underwent TMJ reconstruction had improved quality of life long-term?
85%

Oral Surgery 2 (13 decks)

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