TMJ

Question 1

What supplies synovium to the TMJ

Answer 1

The capsular ligament

Question 2

What is the primary vascular supply to the TMJ

Answer 2

Superficial temporal, maxillary, masseteric arteries

Question 3

What is the nerve supply to the TMJ

Answer 3

auriculotemporal nerve

Question 4

What is your treatment for myofascial pain dysfunction?

Answer 4

NSAIDs, occlusal appliance, soft diet, warm compresses, muscle relaxants (cyclobenzaprine 5 mg nightly), botox injections

Question 5

What is degenerative joint disease?

Answer 5

A chronic inflammatory arthritis resulting in degradation of articular cartilage with remodeling of the subchondral bone

Question 6

What cytokines are found in osteoarthritis

Answer 6

TNF-alpha, IL-1, IL-6

Question 7

What is internal derangement of the TMJ?

Answer 7

Disorder in which the articular disk is in an abnormal position

Question 8

At which Wilkes classification would you consider surgical intervention?

Answer 8

Between Wilkes class 2 and 3. Class 2 does not exhibit bony changes and the disk reduces. I would perform an arthocentesis

Question 9

What are the types of true TMJ ankylosis

Answer 9

Bony, fibrous, fibro-osseous

Question 10

What May cause a pseudoankylosis?

Answer 10

Muscle fibrosis secondary to radiation, myofascial pain, tumors, infection, myositis ossificans

Question 11

Do you know of a classification for ankylosis?

Answer 11

Sawhney- type 1 flattened condylar head with close approximation to joint spaceType 2- flattened condyle close to glenoid fossa, bony fusion on lateral aspectType 3- bony block bridging the ramus and zygomatic archType 4- bony block bridging the ramus, zygomatic arch, replacing complete architecture of joint

Question 12

What is the MIO goal for joint surgery?

Answer 12

At least 35 mm

Question 13

What is the 7 step Kaban protocol?

Answer 13

Pediatric joint replacement1. Resection2. Coronoidectomy on affected side, measure MIO3. Coronoidectomy on other side4. Lining with temporalis myofascial flap or native disc5. Recon with distraction osteogenesis or costrochondral graft6. Early mobilization7. Aggressive physical therapy

Question 14

What imaging would you get for ankylosis and why

Answer 14

CT with contrast. Outline bony mass, evaluate vasculature and planning for custom joint replacement

Question 15

Describe your rib graft harvest

Answer 15

See page 28

Question 16

Describe what a T1 MRI will show?

Answer 16

Fat is bright and will appear white

Question 17

In T1 and T2 how will avascular necrosis appear

Answer 17

T1 marrow will be black and T2 bright

Question 18

Describe what a T2 MRI will show

Answer 18

Water is bright and fat dark. Good for effusions

Question 19

Describe your TMJ HPI

Answer 19

OLD CARTSonsetLocationDurationCharacterAggravating factorsRelieving factorsTimingSeverity

Question 20

Describe your arthrocentesis

Answer 20

IV sedation or general anesthesia. Prep and drape. Scrub and gown. Marking pen for canthal tragal line (Holmlund-Hellsing line). First mark is 10 mm forward and 2 mm down. Second mark is 20 mm forward and 10 mm down. Local anesthetic at the skin. Manipulate jaw to open joint space. Superior joint space entered with 18 gauge needle. Joint space is 3 cc. Second 18 gauge needle. Lavage with at least 100 cc lactated ringers, 400 has been shown to remove inflammatory markers. Inject with kenalog and bupivacaine. Manipulate jaw. Post op exercise, NSAIDs, splints

Question 21

What is the concentration of kenalog injected?

Answer 21

40 mg per ml

Question 22

Describe the layers dissected to enter the joint space

Answer 22

Nerve monitor. Preauricular incision. Facial nerve is 8-35 mm from external auditory meatus. Skin, subcutaneous tissue, temporoparietal fascia, temporalis fascia (glistening white), palpate zygomatic arch, incise through periosteum

Question 23

What layer is the facial nerve found?

Answer 23

Temporal branch within the temporoparietal fascia

Question 24

What is Frey syndrome

Answer 24

Auriculotemporal nerve syndrome. gustatory sweating, flushing, warmth. Auriculotemporal nerve damage. Usually will resolve in 6 months.

Question 25

What is the test for auriculotemporal nerve syndrome?

Answer 25

Iodine starch test (the Minor test). 3 g Iodine, 20 g castor oil, 200 mL absolute alcohol. Lemon drop. Yellow iodine will turn dark blue

Question 26

Aside from waiting what are treatments for auriculotemporal nerve syndrome

Answer 26

40 IU botox. scopolamine ointment. surgical transection of nerve

Question 27

Complication. Your patient is bleeding during condylotomy procedure. Where could the bleed be from?

Answer 27

Internal maxillary artery (runs 3 mm medial from sigmoid notch and 20 mm below condylar head). Bleeding could also be from the masseteric artery

Question 28

Complication. Bleeding during discectomy?

Answer 28

Retrodiscal tissue, lateral pterygoid muscle, middle meningeal artery (31 mm medial to zygomatic arch, 2.4 mm anterior from glenoid fossa)

Question 29

In a carotid artery cut down where is the artery ligated?

Answer 29

Above the facial branch (3rd of the anterior branches)

Question 30

What considerations regarding a Biomet stock prosthesis should you take into account?

Answer 30

The condylar portion is a chromium cobalt alloy and may contain nickel. Nickel allergy would be a contraindication

Question 31

What is the glenoid fossa component made of in a Biomet prosthesis?

Answer 31

Ultra high molecular weight polyethylene

Question 32

What is a TMJ concepts made of?

Answer 32

Condylar component is pure titanium. Fossa component is pure titanium and ultra high molecular weight polyethylene