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Arthroscopic laser surgery for temporomandibular joint disorders
International Congress Series 1248 (2003) 399 – 403
Arthroscopic laser surgery for temporomandibular joint disorders Yoshio Nakano*, Kayoko Ohtsuki, Masatoshi Ohnishi Department of Oral and Maxillofacial Surgery, Yamanashi Medical University, 1110 Shimokatou, Tamaho-tyou, Nakakoma-gun, Yamanashi 409-3898, Japan
Abstract Temporomandibular joint (TMJ) disorders (TMD) are characterized by disturbance of mouth opening, TMJ pain and noise (clicking). The involvement of dislocation and deformation of the disc and the formation of adhesive lesions in the TMJ cavity are characteristic of this disease. With the development of the small endoscope, arthroscopy is now used for both examination and treatment of TMD. We present arthroscopic laser surgery for TMD with a case of rheumatoid TMJ arthritis, with fibrous adhesion, dislocation and anterior disc displacement. The quartz fiber for the Nd:YAG laser was inserted through double-channel cannula into the cavity under the arthroscope. For fiber adhesion, the laser cauterizing was done for excision and cutting off of the adhesion part or the scar tissue. For dislocation and anterior disc displacement, cauterizing was done for the purpose of fresh wound formation on the retrodiscal synovial membrane. To ensure a posterior movement of the disc, suturing was done under the arthroscope. Concerning progress after the operation, excellent result was obtained and it was thought that use of laser with arthroscope was an extremely effective method. D 2003 Elsevier Science B.V. All rights reserved. Keywords: Temporomandibular joint; Arthroscope; Laser surgery; Nd:YAG
1. Introduction Temporomandibular joint (TMJ) disorders (TMD) are characterized by the following symptoms: disturbance of mouth opening, TMJ pain and noise (clicking). Lesions localized in the TMJ cavity are a common pathological condition of TMD together with
* Corresponding author. Tel./fax: +81-55-273-9673. E-mail address: [email protected] (Y. Nakano). 0531-5131/03 D 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0531-5131(03)00040-2
400
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
dislocation and deformation of the disc, and the formation of adhesive lesions in the TMJ cavity are also characteristic of this disease. The surgical procedure of cutting into the TMJ carries a risk, especially in the small TMJ, which is a delicate structure. Arthroscopy of the TMJ was first employed in 1974 by the oral surgeon, Masatoshi Ohnishi of Japan [1]. With the development of the small endoscope and accessory instrumentation, arthroscopy is now used for both examination and treatment of selected conditions affecting the TMJ. We present information about arthroscopic laser surgery for TMD.
2. Method of arthroscopic laser surgery for TMD The patient had fibrous adhesion and dislocation with anterior disc displacement, confirmed by double-contrast CT and MRI. First of all, in the operation, the upper joint cavity had been observed by TMJ arthroscopy. The quartz fiber for the Nd:YAG laser was inserted through double-channel cannula into the cavity under the arthroscope. For the fiber adhesion case, laser cauterizing was done with excision and cutting off of the adhesion part or the scar tissue in the inner wall of the joint. For dislocation and anterior disc displacement, cauterizing was done with the purpose of fresh wound formation on the retrodiscal synovial membrane in the upper joint cavity. Tissue could be vaporized and coagulated on mere contact; no mechanical force was required. As no
Fig. 1. Arthroscopic disc suture and fixation technique. (a) Laser irradiation through quartz fiber to retrodiscal synovial membrane in the upper joint cavity. (b – f) Arthroscopic disc suture.
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
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Fig. 2. Photomicrograph shows effect of Holmium:YAG laser in rabbit TMJ after 2 weeks post-operation. Left: shrinkage between disc (arrow) and condyle (arrowhead) (H&E stain, original magnification 800). Right: welding between disc (arrow) and condyle (arrowhead) (Alcian-Blue stain, original magnification 800).
bleeding was involved, visual fields were good. The laser surgery is the most suitable procedure for arthroscopic surgery. To ensure a posterior movement of the disc, suturing was done under the arthroscope [2,3] (Fig. 1).
3. Animal experiment: effects of Holmium:YAG laser in rabbit TMJ Rabbit TMJ had been exposed and Holmium:YAG laser irradiated on the articular disc. After 2 weeks post-operation, the region of TMJ had been extracted and stained by HE, Alcian Blue and observed. The result was that the disc irradiated by Holmium:YAG laser had been coagulated, shrunk, welded and adhered to a part of the mandibular condyle surface (Fig. 2). For dislocation and anterior disc displacement, it was possible that
Fig. 3. Intra oral findings. Left: pre-treatment. Right: post-treatment.
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Fig. 4. 3D-CT scan showing secondary remodeling of the condyle (arrows). Left: pre-treatment. Right: posttreatment.
Holmium:YAG laser had irradiated on the posterior articular disc to prevent the articular disc from displacement anteriorly.
4. A case of rheumatoid TMJ arthritis This case was a 66-year-old male, who had been unable to masticate as a result of mandibular retrognathia and open bite caused by chronic rheumatoid arthritis. Pre-
Fig. 5. Left: arthrospic laser surgery by double-channel cannula method. Inset: arthrospic image. Right: arthroscopic disc suture and fixation technique. Inset: arthroscopic image.
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
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treatment 3D-CT images showed the condyle deformity and shortening of the mandibular ramus. Intermaxillary traction and arthroscopic disc suture and fixation technique was performed [4]. After the treatment, the open bite disappeared, mastication was regained and correct occlusion was retained without mouth opening disturbance for 1 year 2 months post-treatment, so that his body weight increased. Posttreatment 3D-CT image showed secondary remodeling of the condyle (Figs. 3 – 5).
5. Conclusions The arthroscopic laser surgery is characterized as follows: small operation field compared with general open surgery, application for circulation of saline solution, a predictable operation by contacting probe, shading operation field by fine fiber, a bloodless operation, effect of shrinkage and welding. Concerning progress after the operation, an excellent result was obtained, and it was thought that the use of the laser with arthroscope was an extremely effective method.
References [1] M. Ohnish, Arthroscopy of the temporomandibular joint, Journal of the Stomatological Society Japan 42 (2) (1975) 207 – 213. [2] M. Ohnish, et al., Arthroscopic LASER surgery of the temporomandibular joint, Arthroscopy Japan 11 (1) (1986) 7 – 11. [3] M. Ohnish, Arthroscopic laser surgery and suturing for temporomandibular joint disorders: technique and clinical results, Arthroscopy The Journal of Arthroscopic and Related Surgery 7 (2) (1991) 212 – 220. [4] M. Ohnish, A new therapeutic method for open bite treated by intermaxillary traction and TMJ arthroscopic surgery—a case of chronic rheumatoid arthritis, Journal of the Japanese Society for the Temporomandibular Joint 8 (3) (1996) 534 – 541.
Arthroscopic laser surgery for temporomandibular joint disorders Yoshio Nakano*, Kayoko Ohtsuki, Masatoshi Ohnishi Department of Oral and Maxillofacial Surgery, Yamanashi Medical University, 1110 Shimokatou, Tamaho-tyou, Nakakoma-gun, Yamanashi 409-3898, Japan
Abstract Temporomandibular joint (TMJ) disorders (TMD) are characterized by disturbance of mouth opening, TMJ pain and noise (clicking). The involvement of dislocation and deformation of the disc and the formation of adhesive lesions in the TMJ cavity are characteristic of this disease. With the development of the small endoscope, arthroscopy is now used for both examination and treatment of TMD. We present arthroscopic laser surgery for TMD with a case of rheumatoid TMJ arthritis, with fibrous adhesion, dislocation and anterior disc displacement. The quartz fiber for the Nd:YAG laser was inserted through double-channel cannula into the cavity under the arthroscope. For fiber adhesion, the laser cauterizing was done for excision and cutting off of the adhesion part or the scar tissue. For dislocation and anterior disc displacement, cauterizing was done for the purpose of fresh wound formation on the retrodiscal synovial membrane. To ensure a posterior movement of the disc, suturing was done under the arthroscope. Concerning progress after the operation, excellent result was obtained and it was thought that use of laser with arthroscope was an extremely effective method. D 2003 Elsevier Science B.V. All rights reserved. Keywords: Temporomandibular joint; Arthroscope; Laser surgery; Nd:YAG
1. Introduction Temporomandibular joint (TMJ) disorders (TMD) are characterized by the following symptoms: disturbance of mouth opening, TMJ pain and noise (clicking). Lesions localized in the TMJ cavity are a common pathological condition of TMD together with
* Corresponding author. Tel./fax: +81-55-273-9673. E-mail address: [email protected] (Y. Nakano). 0531-5131/03 D 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0531-5131(03)00040-2
400
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
dislocation and deformation of the disc, and the formation of adhesive lesions in the TMJ cavity are also characteristic of this disease. The surgical procedure of cutting into the TMJ carries a risk, especially in the small TMJ, which is a delicate structure. Arthroscopy of the TMJ was first employed in 1974 by the oral surgeon, Masatoshi Ohnishi of Japan [1]. With the development of the small endoscope and accessory instrumentation, arthroscopy is now used for both examination and treatment of selected conditions affecting the TMJ. We present information about arthroscopic laser surgery for TMD.
2. Method of arthroscopic laser surgery for TMD The patient had fibrous adhesion and dislocation with anterior disc displacement, confirmed by double-contrast CT and MRI. First of all, in the operation, the upper joint cavity had been observed by TMJ arthroscopy. The quartz fiber for the Nd:YAG laser was inserted through double-channel cannula into the cavity under the arthroscope. For the fiber adhesion case, laser cauterizing was done with excision and cutting off of the adhesion part or the scar tissue in the inner wall of the joint. For dislocation and anterior disc displacement, cauterizing was done with the purpose of fresh wound formation on the retrodiscal synovial membrane in the upper joint cavity. Tissue could be vaporized and coagulated on mere contact; no mechanical force was required. As no
Fig. 1. Arthroscopic disc suture and fixation technique. (a) Laser irradiation through quartz fiber to retrodiscal synovial membrane in the upper joint cavity. (b – f) Arthroscopic disc suture.
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
401
Fig. 2. Photomicrograph shows effect of Holmium:YAG laser in rabbit TMJ after 2 weeks post-operation. Left: shrinkage between disc (arrow) and condyle (arrowhead) (H&E stain, original magnification 800). Right: welding between disc (arrow) and condyle (arrowhead) (Alcian-Blue stain, original magnification 800).
bleeding was involved, visual fields were good. The laser surgery is the most suitable procedure for arthroscopic surgery. To ensure a posterior movement of the disc, suturing was done under the arthroscope [2,3] (Fig. 1).
3. Animal experiment: effects of Holmium:YAG laser in rabbit TMJ Rabbit TMJ had been exposed and Holmium:YAG laser irradiated on the articular disc. After 2 weeks post-operation, the region of TMJ had been extracted and stained by HE, Alcian Blue and observed. The result was that the disc irradiated by Holmium:YAG laser had been coagulated, shrunk, welded and adhered to a part of the mandibular condyle surface (Fig. 2). For dislocation and anterior disc displacement, it was possible that
Fig. 3. Intra oral findings. Left: pre-treatment. Right: post-treatment.
402
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
Fig. 4. 3D-CT scan showing secondary remodeling of the condyle (arrows). Left: pre-treatment. Right: posttreatment.
Holmium:YAG laser had irradiated on the posterior articular disc to prevent the articular disc from displacement anteriorly.
4. A case of rheumatoid TMJ arthritis This case was a 66-year-old male, who had been unable to masticate as a result of mandibular retrognathia and open bite caused by chronic rheumatoid arthritis. Pre-
Fig. 5. Left: arthrospic laser surgery by double-channel cannula method. Inset: arthrospic image. Right: arthroscopic disc suture and fixation technique. Inset: arthroscopic image.
Y. Nakano et al. / International Congress Series 1248 (2003) 399–403
403
treatment 3D-CT images showed the condyle deformity and shortening of the mandibular ramus. Intermaxillary traction and arthroscopic disc suture and fixation technique was performed [4]. After the treatment, the open bite disappeared, mastication was regained and correct occlusion was retained without mouth opening disturbance for 1 year 2 months post-treatment, so that his body weight increased. Posttreatment 3D-CT image showed secondary remodeling of the condyle (Figs. 3 – 5).
5. Conclusions The arthroscopic laser surgery is characterized as follows: small operation field compared with general open surgery, application for circulation of saline solution, a predictable operation by contacting probe, shading operation field by fine fiber, a bloodless operation, effect of shrinkage and welding. Concerning progress after the operation, an excellent result was obtained, and it was thought that the use of the laser with arthroscope was an extremely effective method.
References [1] M. Ohnish, Arthroscopy of the temporomandibular joint, Journal of the Stomatological Society Japan 42 (2) (1975) 207 – 213. [2] M. Ohnish, et al., Arthroscopic LASER surgery of the temporomandibular joint, Arthroscopy Japan 11 (1) (1986) 7 – 11. [3] M. Ohnish, Arthroscopic laser surgery and suturing for temporomandibular joint disorders: technique and clinical results, Arthroscopy The Journal of Arthroscopic and Related Surgery 7 (2) (1991) 212 – 220. [4] M. Ohnish, A new therapeutic method for open bite treated by intermaxillary traction and TMJ arthroscopic surgery—a case of chronic rheumatoid arthritis, Journal of the Japanese Society for the Temporomandibular Joint 8 (3) (1996) 534 – 541.