- Email: [email protected]
Arthroscopic laser surgery and suturing for temporomandibular joint disorders: Technique and clinical results
Arthroscopy: The Journal of Arthroscopic and Related Surgery 7(2):212-220 Published by Raven Press, Ltd. 0 1991 Arthroscopy Association of North America
Arthroscopic Laser Surgery and Suturing for Temporomandibular Joint Disorders: Technique and Clinical Results Masatoshi Ohnishi, D.D.S., Ph.D.
Summary: A new surgical technique has been developed to combine arthroscopic laser surgery with suturing to be used clinically in the treatment of temporomandibular joint disorders. This new technique involves the use of a recently invented double-channel cannula needle scope to visualize the lesion. Subsequently, we combined Nd-YAG laser with suturing in the cavity in order to treat the area around the intraarticular wall. The primary use of arthroscopic laser surgery is for treatment of lesions in the inner wall of the joint cavity. In this article, we give an outline of both the arthroscopic laser surgery and the arthroscopic suturing as well as the clinical, postoperative results of these cases. Key Words: Temporomandibular joint-Laser surgery-Nd-YAG laser-Suturing-Double-channel
cannula
method.
method for dealing with temporomandibular joint lesions. This arthroscopic suturing procedure, aimed mainly at the superior area of the articular cavity, was performed in cases of recurrent dislocation, hypermobility, and disc displacement. It was performed primarily on the oblique protuberance in the synovial area extending from the posterior wall to the posterior aspect of the anterior disc. For recurrent dislocation and hypermobility, the procedure was performed deep within the area. In cases of disc displacement, a fresh wound was created by using the Nd-YAG laser to evaporate the surface, and then arthroscopic suturing was performed on the freshened free edge of the articular disc (Figs. l-3).
Temporomandibular arthroscopy has attracted attention for its diagnostic applications and for its therapeutic use (l-7). Despite its small size, the temporomandibular joint has a wide range of motion, including rotating and sliding movements. The temporomandibular joint is functionally complex and is anatomically delicate. For this reason, a small lesion in the temporomandibular joint cavity can present severe functional consequences. Conventional open surgery has been used to treat small intraarticular lesions. This requires extensive surgical invasion as well as involving an area beyond the lesion itself. To reduce the surgically related complications, we have utilized arthroscopic surgery, which is less invasive than conventional types of surgery in the treatment of lesions confined to the temporomandibular joint cavity (8). We have developed, through the use of a Nd-YAG laser and suturing of the lesion through the arthroscope, a new
MATERIALS AND METHODS The subjects of this study were 80 patients with varying joint disorders, representing a total of 138 temporomandibular joints selected from the patients who visited our outpatient clinic from June 1986 to February 1990. These patients were diagnosed by clinical examinations as having intraartic-
From the Department of Oral and Maxillofacial Surgery, Yamanashi Medical College, Tamaho, Yamanashi, Japan. Address correspondence and reprint requests to Dr. M. Ohnishi at Department of Oral and Maxillofacial Surgery, Yamanashi Medical College, 1110 Tamaho, Nakakoma, Yamanashi, 409-38 Japan.
212
ARTHROSCOPIC
SURGERY
FIG. 1. During arthroscopic laser surgery by the double-channel cannula method using a surgical arthroscope. A laser-guiding optical quartz fiber is inserted through a cannula lumen for the surgical instrument, and surgery is performed under television monitoring.
ular lesions that would benefit from arthroscopic laser surgery and arthroscopic suturing. Of these 80 patients, 17 had fibrous adhesions (28 joints), nine had traumatic lesions (fresh injuries; 14 joints), 15 hypermobility problems (subluxation; 26 joints), 15 had habitual dislocation (27 joints), and 24 had anterior disc displacement (37 joints). Preoperatively, the patients were evaluated using physical examination, arthrotomography, and double-contrast computed tomography (CT) scanning of the temporomandibular joint (9,lO). Only those
FIG. 2. Arthroscopic finding during arthroscopic The tip of the laser probe is seen in the center.
laser surgery.
IN TMJ DISORDERS
213
patients who failed to respond to >3 months of conservative therapy and who were suspected of having intraarticular mechanical symptoms were candidates for surgery. The Nd-YAG equipment consisted of MYL-2 (Olympus Optic Co., Japan), Medilas 2, and 40N60N (MBB, Germany). Quartz fibers (Olympus Optic, SLT, MBB) (all 1.0 mm in diameter) were used for the guiding light (Figs. 4 and 5). Arthroscopic laser surgery was performed under intraarticular saline perfusion (30 ml/min) with laser output of 20-35 W, and perfusion temperature maintained at ~40°C. A newly devised, experimental arthroscopic suture needle made of stainless steel was used in the procedure. It consists of two parts: a needle and its holder. The full length is 21 cm, approximately half of which is the needle itself. The eye of the needle is 1.0 mm in diameter at the tip. Depending on the operative case, either i/2 circle or % circle needle tips were used (Fig. 6). The suture material was 3-O monofilament nylon. The basic surgical procedures for arthroscopic laser surgery and arthroscopic suturing followed our usual method (9). The entire procedure was carried out while the joint cavity was viewed via our double-channel cannula using a newly designed needle scope (9,ll) (Figs. 4 and 7). First, a single-channel cannula, with an outer diameter of 2.0 mm, was inserted into the upper temporomandibular joint cavity, and the need for laser surgery assessed. The single-channel cannula then is replaced by an oval-shaped double-channel cannula with an outer diameter of 3.8 x 2.0 mm. An Nd-YAG laser fiber probe then is inserted parallel to the optical tube of the arthroscope in the joint cavity through the opening of the double-channel cannula (Figs. 1, 2, and 5). In cases involving fibrous adhesion, laser cauterization and vaporization are performed to remove both ruptured and tom synovial membrane tissue fragments and inner wall cartilage resulting from the joint injury. In cases involving hypermobility (subluxation), habitual dislocation, and anterior disc displacement, the laser cauterization and vaporization focused upon the oblique protuberance in the upper joint cavity (12) to coagulate deep tissue and form a fresh wound on the surface of the synovial membrane behind the disc. Thereafter, the disc was moved posteriorly and was sutured to form an adhesion and cicatrix between the posterior wall and the posterior aspect of the disc. The disc was
Arthroscopy,
Vol. 7, No. 2, 1991
214
M. OHNISHI
A
D
t
B
-
*
E
moved backward by manipulation with an arthroscopic probe or a hook inserted into the joint cavity by way of an endaural puncture (9). It is difftcult to move the disc backward in cases of severe disc dislocation without reduction. To assure adhesion of the posterior wall and the posterior disc tissue in
FIG. 4. Instruments used in temporomandibular arthroscopic surgery (from the left): quartz fiber for Nd-YAG laser, guiding light, trocar (double- and single-channel cannula and needle), surgical arthroscope, guiding needle, scalpel, forceps, suture needle, and lock-up needle.
Arrhroscopy,
Vol. 7, No. 2, 1991
FIG. 3. Schematic drawing of arthroscopic suturing technique. A: Burning (laser) or incision on the synovial surface for fresh woundmaking. B: Insertion of suturing needle into the joint cavity. C: Puncturing of the needle into the disc, out of the external auditory meatus. The thread pass is allowed to pass through the hole of the needle. D: The needle is moved back again into the joint cavity. E: The needle again is punctured into the posterior wall, out of the meatus. F: The thread is tied, then the disc is pulled back and fixed to the posterior wall of the joint cavity.
c
*
F
such cases, we suture the posterior tissue of the disc to the posterior wall of the joint, and the anterior wall of the external auditory canal by means of our arthroscopic suture method (9,13). The arthroscopic suture needle (Fig. 6) is introduced 10-15 mm anteroinferior to the eminence of
ARTHROSCOPIC
SURGERY
IN TMJ DISORDERS
215
FIG. 7. Double-channel cannula method for temporomandibular arthroscopic surgery. An arthroscope and a surgical instrument are inserted simultaneously into the cannula, and surgery is performed under visualization of the joint cavity with one double channel cannula.
FIG. 5. Laser quartz fibers. Left: Multi-form fiber (MBB Co.). Bight: Bare fiber (SLT Co.).
the temporomandibular joint so that the curve of the needle tip advances from the anterior wall of the superior joint cavity into the cavity itself (Figs. 3B and 8A). When the tip of the arthroscopic needle can be seen in the superior joint cavity with the endoscopic television camera, we carefully advance the needle tip and insert it into the edges of the fresh wound created in the posterior edge of the disc. The tip then is advanced until the needle’s eye is exposed in the external auditory canal (Figs. 3C and 9A). Then, a suture is threaded through the eye, and the tip again is brought back into the joint cavity, where the arthroscope then is manipulated (Figs. 3D and 8B). Next, the tip is inserted into the posterior wall tissue along the posterior edge of the fresh contralateral wound. By doing so, the needle advances through the anteromural skin of the external auditory canal until the eye is exposed (Fig. 3E).
FIG. 6. Arthroscopic suture needle. The eye is 1.O mm in diameter at the tip. Either % or % circle needle tips are used.
When the suture is removed from the eye of the needle and is tied in the external auditory canal, the posterior edge of the articular disc and the posterior wall are approximated (Fig. 3F). If necessary, similar manipulation can be repeated by leaving the suture needle in the joint, enabling continuous tissue suture. To tie stitches, gauze can be used as a cushion to minimize damage to the posteromural skin of the external auditory canal (Fig. 9B). RESULTS Eighty patients (138 temporomandibular joints) were treated by arthroscopic laser surgery including arthroscopic suturing and were postoperatively evaluated by combinations of physical examinations, arthrography, and arthroscopy. This report includes the patients followed for more than 4 months after the initial surgery. Of the 17 patients who underwent separation of fibrous adhesion of the temporomandibular joint to expand the range of mouth opening, 14 could open their mouths >35 mm after surgery. All nine of the patients with acute traumatic lesions of the joint had ~35 mm of mouth opening. There were 30 patients with hypermobility who were treated with the Nd-YAG laser to reduce the range of motion to normal. Fifteen patients were judged to have subluxation, and 13 had successful surgical outcomes. The other 15 habitual dislocations all were relieved of their symptoms. There were 24 patients who complained of the “closed-lock” condition. They were treated with a combination of laser resection and arthroscopic suture. The symptoms disappeared in 23 of the 24 patients following this surgery. Arthroscopy.
Vol. 7, No. 2. 1991
M. OHNISHI
216
FIG. 8. Arthroscooic findings: A: During insertion of the suturing needle into the joint cavity (see Fig. 3B). B: While moving the needle back into the jointcavity (see Fig. 3D).-
Patients with fibrous adhesion of the temporomandibular joint began vigorous open-mouth exercises shortly after surgery to prevent readhesions and to increase the range of mouth opening. Patients with subluxation, habitual dislocation, and disc displacement of the joint were required to restrict jaw movement after surgery to allow for adhesion of the posterior wall and posterior disc. For this reason, their jaws were stabilized with elastic intermaxillary fixation for 2-3 weeks after surgery. Overall, 92% of the 80 patients treated with combinations of arthroscopic laser and/or suture techniques were relieved of their symptoms.
CASE REPORTS Fibrous adhesion case A 45year-old woman had an adhesion of the lateral wall of the left upper joint cavity. Joint cavity stenosis had increased 5 months after surgery. However, the range of mouth opening increased from 17 mm before surgery to 38 mm after (Fig. 10). Habitual dislocation case A 69-year-old man had a bilateral dislocation. Comparison of double-contrast CT scans performed before and 2 months after surgery indicated that the
9A,B
FIG. 9. A: The needle tip is advanced until the needle’s eye is exposed in external auditory canal (see Fig. 3C). B: To tie stitches, gauze is used as a cushion (see Fig. 3F).
Arthroscopy,
Vol. 7, No. 2, I991
ARTHROSCOPIC
SURGERY IN TMJ DISORDERS
217
lOA,B
FIG. 10. Fibrous adhesion case. Upper cavity of the left temporomandibular joint. Double-contrast CT scan, direct sagittal section. A: Before surgery. B: After surgery. The stenosis has increased, but the disc appears to be moved forward.
posterior disc tissue had thickened after surgery and was accompanied by a reduction of the forward shift tissue as well as of the disc. This patient underwent arthroscopic suturing (Fig. 11). Anterior disc displacement case A 20-year-old woman had bilateral disc displacement. Arthroscopic findings 5 months after surgery indicated cicatrix formation and lack of elasticity in the posterior wall, posterior disc tissue, and oblique protuberance. Also, the distance between the disc and the posterior wall in the maximal mouth opening was abridged. A double-contrast CT scan sup-
ported the arthroscopic findings and also indicated a backward shift of the disc (Figs. 12 and 13). DISCUSSION Arthroscopic laser application Although arthroscopic surgery is popular in the field of orthopedic surgery (14,15), the use of lasers in arthroscopic surgery has been attempted mainly in the United States (16,17). By effectively utilizing their characteristics, CO,, Nd-YAG, and Argon lasers all can be used in arthroscopic surgery. Knee
llA,B
Arthroscopy,
Vol. 7. No. 2. 1991
M. OHNISHI
218
FIG. 12. Anterior disc displacement case. Upper cavity of the right temporomandibular joint, double-contrast CT scan, direct sagittal section. A: During maximal mouth opening before surgery. B: After surgery. Note abridgment of the distance between the posterior wall and the posterior disc accompanied by a change in the surface appearance.
surgery, which involves separating and removing torn tissue, is particularly appropriate for CO* lasers. However, the lack of appropriate guidance for intraarticular insertion of the COZ laser remains a problem. In 1980, Inoue (18) studied the separation and vaporization of synovial membranes, meniscus, and articular cartilage by CO, laser. Subsequently, he developed a CO* laser fiber (outer diameter, 6.0 mm) and an arthroscope for surgical use, and reported actual clinical application of these instruments. According to his report (18) the CO2 laser is suitable for cauterizing the synovial membrane with relatively high energy. On the other hand, the NdYAG laser is capable of causing a heat injury on the synovial membrane with relatively low energy. Therefore, the Nd-YAG laser is particularly suited for surgery of the temporomandibular joint for the following reasons: (a) A guiding optic fiber, 0.5 or 1.0 mm in outer diameter, is available that allows for the laser to be easily inserted into the joint cavity. (b) The energy of the Nd-YAG laser is sufficient and can reach a depth of 0.842 mm from the surface (18,19). (c) The Nd-YAG laser is a contact laser and is efficient for joint surgery. Besides resection of adhesions, the laser is capable of producing extensive cicatrix formation in disorders requiring reduction of joint mobility such as subluxation, habitual dislocation, and disc displacement (9,13,19). Arthroscopic laser surgery of the temporomandibular joint Although we have been performing arthroscopic laser surgery for temporomandibular joint disorders since 1985 (19), we know of no other reports of the use of arthroscopic laser surgery in such small joints. Arthroscopy,
Vol. 7, No. 2, 1991
Since it is difficult to perform complex surgical procedures with a laser in the narrow temporomandibular joint cavity, we have found that relying on touch is safer and more accurate in the use of laser radiation. For this reason, we use a direct-contact type quartz fiber. Arthroscopic laser surgery remains of limited use and is confined to simple operations such as the incision, separation, and detachment of small areas of soft tissues such as the synovial membrane, disc tissue, and cartilage. We perform laser surgery with our newly developed double-channel cannula method using a surgical arthroscope (19). The primary objective of Nd-YAG laser surgery are to coagulate, vaporize, and cauterize tissue in the temporomandibular joint cavity to separate adhesive lesions and form a fresh wound on the surface of the synovial membrane. Compared to the forceps and scalpel used for conventional surgery, the laser has a number of advantages. It achieves the same results as other instruments without the use of mechanical force. The energy output can be easily controlled. There is good visualization of the joint cavity during surgery because irrigation distends the joint and controls bleeding. Laser heat is effectively controlled with the use of an irrigating solution (normal saline). By changing energy output, radiation may have various effects on tissue and is, therefore, a reliable method of treating deep tissue as well as the surface layer (11,18,19). Arthroscopic suturing technique in temporomandibular joint In 1989, procedures combining suturing were described by Israel and Ohnishi (9). In their reports,
the arthroscopy and (20), Tarro (21), Israel and Tarro
ARTHROSCOPIC
SURGERY
IN TMJ DISORDERS
219
13A.B
FIG. 13. Arthroscopic findings of anterior displacement cases. A: Upper joint cavity and posterior disc before surgery. B: Five months after operation. Note scarring in the operated area and abridgment of the distance between the posterior disc and the posterior wall.
used the technique in cases of anterior disc displacement for posterior distraction and immobilization. In contrast, the technique devised by the author is for articular mobility control, restricting the opening range in cases of dislocation and disc displacement correction. Suturing procedures of Israel, Tarro, and Ohnishi differ: Israel and Tan-o use a visible triangulation technique with two cannulas in suturing. Israel uses a 20-gauge injection needle, and Tan-o’s technique employs a semicircular suture needle. In both cases, manipulation basically is done blind.
In the procedure we devised, a suture needle is inserted directly into the joint and guided to the site of the suture by using an arthroscope to observe the needle tip. When suturing is complete, the posterior disc shifting and anchoring are confirmed by arthroscopy, which completes the surgical procedure. Lasers were used in all cases covered by this report. All arthroscopic suturing was performed with a double-channel cannula; however, triangulation and a single cannula could also be used. As Israel (20) also describes, simple and accurate manipulation is preferable to complex surgeries because Arthroscopy.
Vol. 7. No. 2. 1991
M.OHNISHi
220
these procedures are performed within the narrow confines of the temporomandibular joint cavity (20). CONCLUSIONS The application of the Nd-YAG laser in temporomandibular arthroscopic surgery proved to be useful in operations on the joint cavity and in producing surgical effects. The arthroscopic suturing technique described, features insertion of a newly developed arthroscopic suture needle directly into the upper joint cavity. Combining this needle with the doublechannel cannula makes this procedure relatively easy and much more accurate. Arthroscopic laser surgery combined with suturing for treatment of selected temporomandibular joint dysfunctions produced good results in 92% of patients after initial surgery. REFERENCES 1, Ohnishi M. Arthroscopy of the temporomandibular joint [in Japanese]. .I Stomarol Sot Jpn 1975;42:207-13. 2. Ohnishi M. Arthroskopische Betrachtungen der Kiefergelenkshohle. In: Acta chirurgiae ma&o facialis. Leipzig: J. A. Barth, 1979:169-170. 3. Holmlund A, Hellsing G. Arthroscopy of the temporomandibular joint: an autopsy study. Int .I Oral Surg 1985;14:16975. 4. Murakami K, Ito K. Arthroscopy of the temporomandibular joint. In: Arthroscopy of small joints. Tokyo: Igaku-Shoin, 1985:121139. 5. Goss AN, Bosanquet AG. Temporomandibular joint arthroscopy. J Oral Maxillofac Surg 1986;4:614-7. 6. 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-I-
7. ggelke
W. Feinnadel-Arthroskopiebefunde
Arthroscopy, Vol. 7, No. 2, 1991
bei patholo-
des Keifergelenks. In: Fortschritte Stuttgart: George Theime Verlag, 1987:4%52. 8. McCain JP. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg 1988;46:648-55. 9. Ohnishi M. Arthroscopic surgery for hypermobility and recurrent mandibular dislocation. Oral and Maxihofacial Surgischen Veranderungen der Kiefer-und
Gesichfs-Chirurgie.
gery Clinics of North America
1989;1:154-63.
”
10. Ohnishi M, Nakayama E, Ohtsuki K. Clinical evaluation of double-contrast computed tomography of the temporomandibular joint [in Japanese, with English abstract]. Jpn J Oral Maxillofac Surg 1989;35: 155-67.
11. Ohnishi M. Newly designed needle scope system for the arthroscopic surgery by double-channel sheath method [in Japanese, with English abstract]. JJpn Sot TMJ 1989;l: l-8. 12. Kino K, Ohnishi M, Shioda S, et al. Morphological observation on the inner surface of the temporomandibular joint: histological investigation relating to the arthroscopic findings in the upper cavity [in Japanese]. Jpn J Oral Surg 1981;27:1379-89. 13. Ohnishi M. Arthroscopy and arthroscopic surgery. In: Cofour atlas and textbook of the temporomandibular thology and surgery. London: Wolfe Publishing,
joint pa-
1990:1IO-
28. 14. Johnson L. Diagnostic and surgical arthroscopy: the knee and other joints. St. Louis: CV Mosby Co, 1981:3-t. 15. Parisien JS. Arthroscopic surgery. New York: McGraw-Hill, 1988:4746. 16. Whipple TI, Caspari RB, Meyers JF. Arthroscopic laser meniscectomy in a gas medium. Arthroscopy 1985;l: 1. 17. Smith JB, Nance TA. Laser energy in arthroscopic surgery, In: Parisien JS, ed. Arthroscopic surgery. New York: McGraw-Hill, 1988:325-30. 18. Inoue K. Arthroscopic laser surgery. In: Itami Y, ed. Arthroscopic diagnosis and arthroscopic surgery [in Japanese]. Tokyo: Kanehara Publishing, 1986:187-97. 19. Ohnishi M. Kanbavashi H. Yonevama Y. Arthroscouic laser surgery of the temporomandibular joint [in Japanese, with English abstract]. Arthroscopy 1986:ll: l-4. 20. Israel HA. Technique for placement of a discal traction suture during temporomandibular joint arthroscopy. .I Oral Maxillofac Surg 1989;47:311-3.
21. Tarro AW. Arthroscopic treatment of anterior disc displacement: a preliminary report. J Oral Maxillofac Surg 1989;47: 353-8.
22. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. 2nd ed. Takyo: Igaku Shoin, 1969:1-30.
Arthroscopic Laser Surgery and Suturing for Temporomandibular Joint Disorders: Technique and Clinical Results Masatoshi Ohnishi, D.D.S., Ph.D.
Summary: A new surgical technique has been developed to combine arthroscopic laser surgery with suturing to be used clinically in the treatment of temporomandibular joint disorders. This new technique involves the use of a recently invented double-channel cannula needle scope to visualize the lesion. Subsequently, we combined Nd-YAG laser with suturing in the cavity in order to treat the area around the intraarticular wall. The primary use of arthroscopic laser surgery is for treatment of lesions in the inner wall of the joint cavity. In this article, we give an outline of both the arthroscopic laser surgery and the arthroscopic suturing as well as the clinical, postoperative results of these cases. Key Words: Temporomandibular joint-Laser surgery-Nd-YAG laser-Suturing-Double-channel
cannula
method.
method for dealing with temporomandibular joint lesions. This arthroscopic suturing procedure, aimed mainly at the superior area of the articular cavity, was performed in cases of recurrent dislocation, hypermobility, and disc displacement. It was performed primarily on the oblique protuberance in the synovial area extending from the posterior wall to the posterior aspect of the anterior disc. For recurrent dislocation and hypermobility, the procedure was performed deep within the area. In cases of disc displacement, a fresh wound was created by using the Nd-YAG laser to evaporate the surface, and then arthroscopic suturing was performed on the freshened free edge of the articular disc (Figs. l-3).
Temporomandibular arthroscopy has attracted attention for its diagnostic applications and for its therapeutic use (l-7). Despite its small size, the temporomandibular joint has a wide range of motion, including rotating and sliding movements. The temporomandibular joint is functionally complex and is anatomically delicate. For this reason, a small lesion in the temporomandibular joint cavity can present severe functional consequences. Conventional open surgery has been used to treat small intraarticular lesions. This requires extensive surgical invasion as well as involving an area beyond the lesion itself. To reduce the surgically related complications, we have utilized arthroscopic surgery, which is less invasive than conventional types of surgery in the treatment of lesions confined to the temporomandibular joint cavity (8). We have developed, through the use of a Nd-YAG laser and suturing of the lesion through the arthroscope, a new
MATERIALS AND METHODS The subjects of this study were 80 patients with varying joint disorders, representing a total of 138 temporomandibular joints selected from the patients who visited our outpatient clinic from June 1986 to February 1990. These patients were diagnosed by clinical examinations as having intraartic-
From the Department of Oral and Maxillofacial Surgery, Yamanashi Medical College, Tamaho, Yamanashi, Japan. Address correspondence and reprint requests to Dr. M. Ohnishi at Department of Oral and Maxillofacial Surgery, Yamanashi Medical College, 1110 Tamaho, Nakakoma, Yamanashi, 409-38 Japan.
212
ARTHROSCOPIC
SURGERY
FIG. 1. During arthroscopic laser surgery by the double-channel cannula method using a surgical arthroscope. A laser-guiding optical quartz fiber is inserted through a cannula lumen for the surgical instrument, and surgery is performed under television monitoring.
ular lesions that would benefit from arthroscopic laser surgery and arthroscopic suturing. Of these 80 patients, 17 had fibrous adhesions (28 joints), nine had traumatic lesions (fresh injuries; 14 joints), 15 hypermobility problems (subluxation; 26 joints), 15 had habitual dislocation (27 joints), and 24 had anterior disc displacement (37 joints). Preoperatively, the patients were evaluated using physical examination, arthrotomography, and double-contrast computed tomography (CT) scanning of the temporomandibular joint (9,lO). Only those
FIG. 2. Arthroscopic finding during arthroscopic The tip of the laser probe is seen in the center.
laser surgery.
IN TMJ DISORDERS
213
patients who failed to respond to >3 months of conservative therapy and who were suspected of having intraarticular mechanical symptoms were candidates for surgery. The Nd-YAG equipment consisted of MYL-2 (Olympus Optic Co., Japan), Medilas 2, and 40N60N (MBB, Germany). Quartz fibers (Olympus Optic, SLT, MBB) (all 1.0 mm in diameter) were used for the guiding light (Figs. 4 and 5). Arthroscopic laser surgery was performed under intraarticular saline perfusion (30 ml/min) with laser output of 20-35 W, and perfusion temperature maintained at ~40°C. A newly devised, experimental arthroscopic suture needle made of stainless steel was used in the procedure. It consists of two parts: a needle and its holder. The full length is 21 cm, approximately half of which is the needle itself. The eye of the needle is 1.0 mm in diameter at the tip. Depending on the operative case, either i/2 circle or % circle needle tips were used (Fig. 6). The suture material was 3-O monofilament nylon. The basic surgical procedures for arthroscopic laser surgery and arthroscopic suturing followed our usual method (9). The entire procedure was carried out while the joint cavity was viewed via our double-channel cannula using a newly designed needle scope (9,ll) (Figs. 4 and 7). First, a single-channel cannula, with an outer diameter of 2.0 mm, was inserted into the upper temporomandibular joint cavity, and the need for laser surgery assessed. The single-channel cannula then is replaced by an oval-shaped double-channel cannula with an outer diameter of 3.8 x 2.0 mm. An Nd-YAG laser fiber probe then is inserted parallel to the optical tube of the arthroscope in the joint cavity through the opening of the double-channel cannula (Figs. 1, 2, and 5). In cases involving fibrous adhesion, laser cauterization and vaporization are performed to remove both ruptured and tom synovial membrane tissue fragments and inner wall cartilage resulting from the joint injury. In cases involving hypermobility (subluxation), habitual dislocation, and anterior disc displacement, the laser cauterization and vaporization focused upon the oblique protuberance in the upper joint cavity (12) to coagulate deep tissue and form a fresh wound on the surface of the synovial membrane behind the disc. Thereafter, the disc was moved posteriorly and was sutured to form an adhesion and cicatrix between the posterior wall and the posterior aspect of the disc. The disc was
Arthroscopy,
Vol. 7, No. 2, 1991
214
M. OHNISHI
A
D
t
B
-
*
E
moved backward by manipulation with an arthroscopic probe or a hook inserted into the joint cavity by way of an endaural puncture (9). It is difftcult to move the disc backward in cases of severe disc dislocation without reduction. To assure adhesion of the posterior wall and the posterior disc tissue in
FIG. 4. Instruments used in temporomandibular arthroscopic surgery (from the left): quartz fiber for Nd-YAG laser, guiding light, trocar (double- and single-channel cannula and needle), surgical arthroscope, guiding needle, scalpel, forceps, suture needle, and lock-up needle.
Arrhroscopy,
Vol. 7, No. 2, 1991
FIG. 3. Schematic drawing of arthroscopic suturing technique. A: Burning (laser) or incision on the synovial surface for fresh woundmaking. B: Insertion of suturing needle into the joint cavity. C: Puncturing of the needle into the disc, out of the external auditory meatus. The thread pass is allowed to pass through the hole of the needle. D: The needle is moved back again into the joint cavity. E: The needle again is punctured into the posterior wall, out of the meatus. F: The thread is tied, then the disc is pulled back and fixed to the posterior wall of the joint cavity.
c
*
F
such cases, we suture the posterior tissue of the disc to the posterior wall of the joint, and the anterior wall of the external auditory canal by means of our arthroscopic suture method (9,13). The arthroscopic suture needle (Fig. 6) is introduced 10-15 mm anteroinferior to the eminence of
ARTHROSCOPIC
SURGERY
IN TMJ DISORDERS
215
FIG. 7. Double-channel cannula method for temporomandibular arthroscopic surgery. An arthroscope and a surgical instrument are inserted simultaneously into the cannula, and surgery is performed under visualization of the joint cavity with one double channel cannula.
FIG. 5. Laser quartz fibers. Left: Multi-form fiber (MBB Co.). Bight: Bare fiber (SLT Co.).
the temporomandibular joint so that the curve of the needle tip advances from the anterior wall of the superior joint cavity into the cavity itself (Figs. 3B and 8A). When the tip of the arthroscopic needle can be seen in the superior joint cavity with the endoscopic television camera, we carefully advance the needle tip and insert it into the edges of the fresh wound created in the posterior edge of the disc. The tip then is advanced until the needle’s eye is exposed in the external auditory canal (Figs. 3C and 9A). Then, a suture is threaded through the eye, and the tip again is brought back into the joint cavity, where the arthroscope then is manipulated (Figs. 3D and 8B). Next, the tip is inserted into the posterior wall tissue along the posterior edge of the fresh contralateral wound. By doing so, the needle advances through the anteromural skin of the external auditory canal until the eye is exposed (Fig. 3E).
FIG. 6. Arthroscopic suture needle. The eye is 1.O mm in diameter at the tip. Either % or % circle needle tips are used.
When the suture is removed from the eye of the needle and is tied in the external auditory canal, the posterior edge of the articular disc and the posterior wall are approximated (Fig. 3F). If necessary, similar manipulation can be repeated by leaving the suture needle in the joint, enabling continuous tissue suture. To tie stitches, gauze can be used as a cushion to minimize damage to the posteromural skin of the external auditory canal (Fig. 9B). RESULTS Eighty patients (138 temporomandibular joints) were treated by arthroscopic laser surgery including arthroscopic suturing and were postoperatively evaluated by combinations of physical examinations, arthrography, and arthroscopy. This report includes the patients followed for more than 4 months after the initial surgery. Of the 17 patients who underwent separation of fibrous adhesion of the temporomandibular joint to expand the range of mouth opening, 14 could open their mouths >35 mm after surgery. All nine of the patients with acute traumatic lesions of the joint had ~35 mm of mouth opening. There were 30 patients with hypermobility who were treated with the Nd-YAG laser to reduce the range of motion to normal. Fifteen patients were judged to have subluxation, and 13 had successful surgical outcomes. The other 15 habitual dislocations all were relieved of their symptoms. There were 24 patients who complained of the “closed-lock” condition. They were treated with a combination of laser resection and arthroscopic suture. The symptoms disappeared in 23 of the 24 patients following this surgery. Arthroscopy.
Vol. 7, No. 2. 1991
M. OHNISHI
216
FIG. 8. Arthroscooic findings: A: During insertion of the suturing needle into the joint cavity (see Fig. 3B). B: While moving the needle back into the jointcavity (see Fig. 3D).-
Patients with fibrous adhesion of the temporomandibular joint began vigorous open-mouth exercises shortly after surgery to prevent readhesions and to increase the range of mouth opening. Patients with subluxation, habitual dislocation, and disc displacement of the joint were required to restrict jaw movement after surgery to allow for adhesion of the posterior wall and posterior disc. For this reason, their jaws were stabilized with elastic intermaxillary fixation for 2-3 weeks after surgery. Overall, 92% of the 80 patients treated with combinations of arthroscopic laser and/or suture techniques were relieved of their symptoms.
CASE REPORTS Fibrous adhesion case A 45year-old woman had an adhesion of the lateral wall of the left upper joint cavity. Joint cavity stenosis had increased 5 months after surgery. However, the range of mouth opening increased from 17 mm before surgery to 38 mm after (Fig. 10). Habitual dislocation case A 69-year-old man had a bilateral dislocation. Comparison of double-contrast CT scans performed before and 2 months after surgery indicated that the
9A,B
FIG. 9. A: The needle tip is advanced until the needle’s eye is exposed in external auditory canal (see Fig. 3C). B: To tie stitches, gauze is used as a cushion (see Fig. 3F).
Arthroscopy,
Vol. 7, No. 2, I991
ARTHROSCOPIC
SURGERY IN TMJ DISORDERS
217
lOA,B
FIG. 10. Fibrous adhesion case. Upper cavity of the left temporomandibular joint. Double-contrast CT scan, direct sagittal section. A: Before surgery. B: After surgery. The stenosis has increased, but the disc appears to be moved forward.
posterior disc tissue had thickened after surgery and was accompanied by a reduction of the forward shift tissue as well as of the disc. This patient underwent arthroscopic suturing (Fig. 11). Anterior disc displacement case A 20-year-old woman had bilateral disc displacement. Arthroscopic findings 5 months after surgery indicated cicatrix formation and lack of elasticity in the posterior wall, posterior disc tissue, and oblique protuberance. Also, the distance between the disc and the posterior wall in the maximal mouth opening was abridged. A double-contrast CT scan sup-
ported the arthroscopic findings and also indicated a backward shift of the disc (Figs. 12 and 13). DISCUSSION Arthroscopic laser application Although arthroscopic surgery is popular in the field of orthopedic surgery (14,15), the use of lasers in arthroscopic surgery has been attempted mainly in the United States (16,17). By effectively utilizing their characteristics, CO,, Nd-YAG, and Argon lasers all can be used in arthroscopic surgery. Knee
llA,B
Arthroscopy,
Vol. 7. No. 2. 1991
M. OHNISHI
218
FIG. 12. Anterior disc displacement case. Upper cavity of the right temporomandibular joint, double-contrast CT scan, direct sagittal section. A: During maximal mouth opening before surgery. B: After surgery. Note abridgment of the distance between the posterior wall and the posterior disc accompanied by a change in the surface appearance.
surgery, which involves separating and removing torn tissue, is particularly appropriate for CO* lasers. However, the lack of appropriate guidance for intraarticular insertion of the COZ laser remains a problem. In 1980, Inoue (18) studied the separation and vaporization of synovial membranes, meniscus, and articular cartilage by CO, laser. Subsequently, he developed a CO* laser fiber (outer diameter, 6.0 mm) and an arthroscope for surgical use, and reported actual clinical application of these instruments. According to his report (18) the CO2 laser is suitable for cauterizing the synovial membrane with relatively high energy. On the other hand, the NdYAG laser is capable of causing a heat injury on the synovial membrane with relatively low energy. Therefore, the Nd-YAG laser is particularly suited for surgery of the temporomandibular joint for the following reasons: (a) A guiding optic fiber, 0.5 or 1.0 mm in outer diameter, is available that allows for the laser to be easily inserted into the joint cavity. (b) The energy of the Nd-YAG laser is sufficient and can reach a depth of 0.842 mm from the surface (18,19). (c) The Nd-YAG laser is a contact laser and is efficient for joint surgery. Besides resection of adhesions, the laser is capable of producing extensive cicatrix formation in disorders requiring reduction of joint mobility such as subluxation, habitual dislocation, and disc displacement (9,13,19). Arthroscopic laser surgery of the temporomandibular joint Although we have been performing arthroscopic laser surgery for temporomandibular joint disorders since 1985 (19), we know of no other reports of the use of arthroscopic laser surgery in such small joints. Arthroscopy,
Vol. 7, No. 2, 1991
Since it is difficult to perform complex surgical procedures with a laser in the narrow temporomandibular joint cavity, we have found that relying on touch is safer and more accurate in the use of laser radiation. For this reason, we use a direct-contact type quartz fiber. Arthroscopic laser surgery remains of limited use and is confined to simple operations such as the incision, separation, and detachment of small areas of soft tissues such as the synovial membrane, disc tissue, and cartilage. We perform laser surgery with our newly developed double-channel cannula method using a surgical arthroscope (19). The primary objective of Nd-YAG laser surgery are to coagulate, vaporize, and cauterize tissue in the temporomandibular joint cavity to separate adhesive lesions and form a fresh wound on the surface of the synovial membrane. Compared to the forceps and scalpel used for conventional surgery, the laser has a number of advantages. It achieves the same results as other instruments without the use of mechanical force. The energy output can be easily controlled. There is good visualization of the joint cavity during surgery because irrigation distends the joint and controls bleeding. Laser heat is effectively controlled with the use of an irrigating solution (normal saline). By changing energy output, radiation may have various effects on tissue and is, therefore, a reliable method of treating deep tissue as well as the surface layer (11,18,19). Arthroscopic suturing technique in temporomandibular joint In 1989, procedures combining suturing were described by Israel and Ohnishi (9). In their reports,
the arthroscopy and (20), Tarro (21), Israel and Tarro
ARTHROSCOPIC
SURGERY
IN TMJ DISORDERS
219
13A.B
FIG. 13. Arthroscopic findings of anterior displacement cases. A: Upper joint cavity and posterior disc before surgery. B: Five months after operation. Note scarring in the operated area and abridgment of the distance between the posterior disc and the posterior wall.
used the technique in cases of anterior disc displacement for posterior distraction and immobilization. In contrast, the technique devised by the author is for articular mobility control, restricting the opening range in cases of dislocation and disc displacement correction. Suturing procedures of Israel, Tarro, and Ohnishi differ: Israel and Tan-o use a visible triangulation technique with two cannulas in suturing. Israel uses a 20-gauge injection needle, and Tan-o’s technique employs a semicircular suture needle. In both cases, manipulation basically is done blind.
In the procedure we devised, a suture needle is inserted directly into the joint and guided to the site of the suture by using an arthroscope to observe the needle tip. When suturing is complete, the posterior disc shifting and anchoring are confirmed by arthroscopy, which completes the surgical procedure. Lasers were used in all cases covered by this report. All arthroscopic suturing was performed with a double-channel cannula; however, triangulation and a single cannula could also be used. As Israel (20) also describes, simple and accurate manipulation is preferable to complex surgeries because Arthroscopy.
Vol. 7. No. 2. 1991
M.OHNISHi
220
these procedures are performed within the narrow confines of the temporomandibular joint cavity (20). CONCLUSIONS The application of the Nd-YAG laser in temporomandibular arthroscopic surgery proved to be useful in operations on the joint cavity and in producing surgical effects. The arthroscopic suturing technique described, features insertion of a newly developed arthroscopic suture needle directly into the upper joint cavity. Combining this needle with the doublechannel cannula makes this procedure relatively easy and much more accurate. Arthroscopic laser surgery combined with suturing for treatment of selected temporomandibular joint dysfunctions produced good results in 92% of patients after initial surgery. REFERENCES 1, Ohnishi M. Arthroscopy of the temporomandibular joint [in Japanese]. .I Stomarol Sot Jpn 1975;42:207-13. 2. Ohnishi M. Arthroskopische Betrachtungen der Kiefergelenkshohle. In: Acta chirurgiae ma&o facialis. Leipzig: J. A. Barth, 1979:169-170. 3. Holmlund A, Hellsing G. Arthroscopy of the temporomandibular joint: an autopsy study. Int .I Oral Surg 1985;14:16975. 4. Murakami K, Ito K. Arthroscopy of the temporomandibular joint. In: Arthroscopy of small joints. Tokyo: Igaku-Shoin, 1985:121139. 5. Goss AN, Bosanquet AG. Temporomandibular joint arthroscopy. J Oral Maxillofac Surg 1986;4:614-7. 6. 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-I-
7. ggelke
W. Feinnadel-Arthroskopiebefunde
Arthroscopy, Vol. 7, No. 2, 1991
bei patholo-
des Keifergelenks. In: Fortschritte Stuttgart: George Theime Verlag, 1987:4%52. 8. McCain JP. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg 1988;46:648-55. 9. Ohnishi M. Arthroscopic surgery for hypermobility and recurrent mandibular dislocation. Oral and Maxihofacial Surgischen Veranderungen der Kiefer-und
Gesichfs-Chirurgie.
gery Clinics of North America
1989;1:154-63.
”
10. Ohnishi M, Nakayama E, Ohtsuki K. Clinical evaluation of double-contrast computed tomography of the temporomandibular joint [in Japanese, with English abstract]. Jpn J Oral Maxillofac Surg 1989;35: 155-67.
11. Ohnishi M. Newly designed needle scope system for the arthroscopic surgery by double-channel sheath method [in Japanese, with English abstract]. JJpn Sot TMJ 1989;l: l-8. 12. Kino K, Ohnishi M, Shioda S, et al. Morphological observation on the inner surface of the temporomandibular joint: histological investigation relating to the arthroscopic findings in the upper cavity [in Japanese]. Jpn J Oral Surg 1981;27:1379-89. 13. Ohnishi M. Arthroscopy and arthroscopic surgery. In: Cofour atlas and textbook of the temporomandibular thology and surgery. London: Wolfe Publishing,
joint pa-
1990:1IO-
28. 14. Johnson L. Diagnostic and surgical arthroscopy: the knee and other joints. St. Louis: CV Mosby Co, 1981:3-t. 15. Parisien JS. Arthroscopic surgery. New York: McGraw-Hill, 1988:4746. 16. Whipple TI, Caspari RB, Meyers JF. Arthroscopic laser meniscectomy in a gas medium. Arthroscopy 1985;l: 1. 17. Smith JB, Nance TA. Laser energy in arthroscopic surgery, In: Parisien JS, ed. Arthroscopic surgery. New York: McGraw-Hill, 1988:325-30. 18. Inoue K. Arthroscopic laser surgery. In: Itami Y, ed. Arthroscopic diagnosis and arthroscopic surgery [in Japanese]. Tokyo: Kanehara Publishing, 1986:187-97. 19. Ohnishi M. Kanbavashi H. Yonevama Y. Arthroscouic laser surgery of the temporomandibular joint [in Japanese, with English abstract]. Arthroscopy 1986:ll: l-4. 20. Israel HA. Technique for placement of a discal traction suture during temporomandibular joint arthroscopy. .I Oral Maxillofac Surg 1989;47:311-3.
21. Tarro AW. Arthroscopic treatment of anterior disc displacement: a preliminary report. J Oral Maxillofac Surg 1989;47: 353-8.
22. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. 2nd ed. Takyo: Igaku Shoin, 1969:1-30.