Eminectomy and meniscorhaphy for internal derangements of the temporomandibular joint

Eminectomy and meniscorhaphy for internal derangements of the temporomandibular joint Rationale and operative

technique

Simon Weinberg, D.D.S., F.R.C.D.(C).* FACULTY

OF DENTISTRY.

UNIVERSITY

Toronto, Ontario, Canada

OF TORONTO

To date, most reports of surgical procedures to correct anterior meniscal displacement have focused on excision and repair of redundant posterior attachment tissue in conjunction with some form of arthroplasty. A procedure involving direct plication of the fibrous disk to the articular capsule (meniscorhaphy) and excision of the articular eminence (eminectomy) has yielded good results in most of the thirty-three patients with internal TMJ derangements on whom this operation has been performed within the past 44 months. The procedure is uncomplicated and physiologically sound, and it satisfies the concept of intracapsular decompression which is developed and described in this article. When surgical intervention is indicated for patients with internal TMJ derangements, eminectomy and meniscorhaphy should be given strong consideration.

E

xcision of the articular eminence of the temporal bone (eminectomy), initially described by Myrhaug,’ has been well documented by several authorsze9 as a successful technique for management of chronic recurrent temporomandibular joint luxation or subluxation. Irby’O briefly states his favorable experience with this procedure in treating patients with TMJ pain and dysfunction who did not respond to conservative therapy. During the past 44 months, forty eminectomies and meniscorhaphies have been performed on thirtythree patients with refractory internal TMJ derangements. This number represents approximately 6% of all patients with TMJ-related complaints examined during that period. The diagnosis was based on the classic symptom triad of pain, limitation of motion, and joint sounds. Osteoarthrotic changes were not seen in the transpharyngeal and tomographic surveys of the joint that were carried out in each case. Although arthrograms were not taken, the observed signs and reported symptoms were compatible in every instance with those noted for internal derangement as depicted by arthrography and described so

*Associate

Professor

of Oral

and Maxillofacial

Surgery.

aptly by Wilkes,” Katzberg,‘* Dolwick,‘3 Farrar,‘” and Blaschke” and their coauthors. The purpose of this article is to discuss the rationale for and describe the technique of eminectomy and meniscal plication as a highly effective operation when surgery is indicated for the treatment of patients with internal derangements of the tempo romandibular joint. This operation has also been used successfully, in combination with arthroplasty, to manage patients who have intractable TMJ pain related to advanced osteoarthrosis. RATIONALE

The current resurgence of TMJ arthrography, pioneered by Norgaard16 in 1944 and reported by Campbell” in 1965 and Toiler’* in 1974, shows strong evidence that the majority of patients with TMJ pain and dysfunction also have some degree of meniscal displacement, usually in an anterior or anteromedial direction, when the teeth are in centric occlusion.“-‘5 Some authors’9-2’ have considered the anterior dense collagenous portion of the disk as the full extent of the meniscus. Functionally defined, however, the intra-articular meniscus should include the 241

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1. Diagrammatic representation of bilaminar pattern of posterior attachment of meniscus.

Fig.

2. Diagram illustrating compression of neurovascular zone of posterior attachment between condyle and eminence.

Fig.

elastic and neurovascular zones (bilaminar zone, posterior attachment) which intervene between the coilagenous portion of the disk and the posterior wall of the joint capsule.22s23(Fig. 1). This spongy bilaminar zone consists of an upper stratum composed of loose fibroelastic tissue which is attached to the posterior wall of the glenoid fossa and squamotympanic suture. This lamina is thought to represent the diskomalleolar band of fetal life, which connects the lateral pterygoid tendon to the malleus through the squamotympanic suture (Pinto’s ligament).24 The lower stratum is composed chiefly of fibrous tissue that contains numerous vascular chan-

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nels and nerve fibers of the freely ending variety, which are derived primarily from the auriculotemporal nerve, with lesser contributions from the posterior deep temporal and masseteric nerves.22 These fibers are generally thought to transmit pain information.23.25 Relatively few elastic fibers are found in this lower stratum.22,23 The recent work of Wheelock and Mercuri29 has shown that the elastic fibers in the lower stratum form a thin but distinct and welldefined lamina beneath the neurovascular zone. This posterior attachment is therefore more accurately described as a trilaminar, rather than bilaminar, region, and the competency of the elastic component of this area plays a major role in normal joint function and in the etiology of internal derangement (anterior meniscal displacement).‘L-‘3 As the mandibular condyle moves down and forward onto the crest of the articular eminence during opening or protrusive movements, it is accompanied by the articular disk, because of the meniscal attachments to the medial and lateral poles of the condyle and traction by the superior head of the lateral pterygoid muscle. The degree of stretching or tension within the elastic tissue of the bilaminar region and its temporal attachment appears to limit excessive excursions of the disk in this direction.23 The potential spaces behind the meniscus and the condyle are filled with the thick and loose bilaminar region that is drawn into the vacated glenoid fossa from the posterolateral aspect of the joint when the condyle is in a protruded position. The vascular spaces in the posterior attachment distend with blood to partially fill the empty fossa. When the jaws are closed, this sequence of events is reversed and the disk is returned to its resting position, aided by the recoil of the posterosuperiorly oriented elastic fibers in the posterior attachment; as the retruding condyle resumes its fossal seat, the dilated vascular components are compressed and emptied.22, 23 In addition to the neurovascular zone of the posterior attachment, free nerve endings are most abundant in the posterior and lateral aspects of the capsule and are also found in the ligaments, synovial membrane, periosteum, and cancellous bone.25-27As in other joints, the stress-bearing tissues (that is, the articular surfaces, the central zone of the disk, and compact bone) are not innervated, and therefore pain is not perceived when pressure is applied to these structures.28. 2o Pain receptors may be stimulated by any condition that raises intracapsular pressure, resulting in capsular distension and increased tension on the capsular fibers.30 This may be primary, the result of direct

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4. Skin incision and Middleton’s line marked on

skin. 3. Diagram showing potential for increasing the capacity of the superior joint space by excision of articular eminence.

Fig.

injury to the capsule itself, with stretching or tearing of the capsular fibers (capsulitis), or secondary to increased intracapsular pressure induced by inflammatory edema, blood, or expanding lesions (for example, hyperplasia or neoplasia). It is conceivable that anterior mensical displacement may be produced by overt trauma to the region of the joint or by the more insidious injury resulting from prolonged muscular hyperactivity secondary to local factors (for example, occlusal interferences, arthroses) or central influence (for example, emotional stress).30 Prolonged hyperactivity of the superior head of the lateral pterygoid muscle that inserts into the anteromedial rim of the disk3’*32 may initially result in a stretching and/or disruption of the elastic fibers in the posterior attachment.” This reduction or loss of elastic recoil will cause the meniscus to remain displaced anteriorly, and during closure the condyle will slip or snap behind the posterior band of the nonreturning disk and compress the free nerve endings in the neurovascular zone of the posterior attachment (Fig. 2). Impingement upon these free nerve endings, between the condyle and the posterior slope of the articular eminence, will elicit pain and perpetuate the anterior displacement of the intraarticular disk.1’-‘3s33 The posterior attachment of the disk may subsequently herniate and perforate, giving rise to proliferative and/or degenerative structural changes characteristic of osteoarthrosis.34 Resting pain is not a prominent symptom of anterior meniscal displacement; the pain is motion related and appears to reach maximum intensity when the condylar head reaches the posterior slope

Fig. 5. Outer layer of temporal fascia exposedto level approximately 2.0 cm above zygomatic arch.

or summit of the articular eminence,‘O the compressive force exerted by the condyle against the free nerve endings in the bilaminar zone being greatest in these anatomic situations3) Excision of the articular eminence (eminectomy) rapidly and effectively decompresses the intracapsular compartment by creating a larger anterior recess in the superior joint space (Fig. 3) This allows free unrestricted movement of the meniscus without entrapment of the neurovascular zone of the posterior attachment. Indirectly, the principle of intracapsular decompression has formed the basis for the majority of surgical procedures that have been used to treat the painful TMJ.

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Fig. 6. Articular eminence exposed and scored horizontally with fissure bur in high-speed drill.

REVIEW OF SURGERY FOR THE PAINFUL TMJ

Meniscectomy, high condylectomy, osteotomy of the condylar neck (condylotomy), and arthroplasty and meniscal repositioning are the four basic operations that have been described for treatment of the painful TMJ. Meniscectomy

Although men&al surgery was first described in 1887 by Annandale,35 who repaired a torn meniscus through a preauricular approach, meniscectomy was initially reported by Lanz3’j in 1909, followed by Pringle3’ and Wakely3* in 1918 and 1929, respectively. After a hiatus of several years, the operation was reported by Boman39 in 1947 and appeared to be strongly advocated in the 1950s in reports by Dingman and Moorman40 Kiehn,41 Rongetti42 and Silver and Simon43 as a high-priority surgical treatment for TMJ derangements and painful dysfunction associated with degenerative arthritis. Since that time, however, primarily because of a high recurrence of symptoms, lo TMJ meniscectomy appears to have fallen steadily into disfavor. The rationale for this procedure paralleled that for meniscectomy of the knee joint and was empirically based upon the presumptive diagnosis of a displaced, torn, herniated, and/or perforated meniscus acting as an irritant and producing an intracapsular inflammatory response characterized by pain, edema, limitation of motion, and mechanical blockade. The reported complications of meniscectomy have included pain, limitation of movement, persistent crepitation, and, in rare instances, fibrous ankylosis; gross radiographic changes in the joint have also been observed. Meniscectomy in the rabbit has been shown to produce compensatory changes in the articulating surface of the condyle.44

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Fig. 7. Entire mediolateral is removed.

extent of articular

Surg. 1984

eminence

The importance of maintaining meniscal integrity during TMJ surgery has been supported by the animal experiments of J01ly~~ and Poswillo,46 whose work emphasizes the cardinal role of the disk in repair of the surgically treated condylar head. Poswillo’s44 statement reflects the current opinion of most experienced workers in the field: “The role of meniscectomy in the treatment of painful, clicking temporomandibular joints should be relegated to that of an operative procedure of historical significance only.” High condylectomy shave)

(arthroplasty, high condylar

Following Ireland’s4’ report in 195 1, describing condylectomy for treatment of anterior meniscal dislocation, Henny and Baldridge, in 1957, discussed high condylectomy (arthroplasty) as a successful treatment for patients with TMJ pain and dysfunction who showed radiographic evidence of joint disease and did not respond to conservative therapy. They rationalized that the roughened and pitted condylar head acts as a painful irritant to the sensory nerves in the joint and that excision of the articular surface of the condyle, in the form of a wafer approximately 4 to 5 mm. thick, above the insertion of the inferior head of the lateral pterygoid muscle would eliminate the source of pain without producing major changes in joint function and occlusion, The success attributed to high condylectomy for the management of chronic TMJ pain and dysfunction in those patients who show radiographic evidence of joint disease may well be due to the reduction in intracapsular pressure that occurs when the mass of the condyle is reduced and to the corresponding increase in the capacity of the inferior

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Fig. 8. After eminectomy, the anterior recess of the superior joint space is significantly increased in capacity. Note the excellent visibility of the superior surface of the fibrous disk.

joint space. This structural rearrangement would tend to relieve the compressive effect exerted by the condyle against the free nerve endings in the bilaminar zone of the disk during condylar movement in those cases of condylar-men&al incoordination that result from anterior displacement of the disk. A minor surgical variation of high condylectomy, termed intracapsular arthroplasty or condyloplasty, was described by Dingman and Grabb.49 Their technique simply involves a smoothing and reshaping of the roughened condylar articular surface, rather than en block excision. Adequate exposure of the condylar surface is achieved by distracting the angle of the mandible with a transosseous wire suture. The indications for this operation are similar to those for high condylectomy. Poswillo’s46 work with near-human primates has shown that the optimum long-term effect of condylectomy or high condylectomy is the regeneration of a functional condyle whose articular surface is capped by a veneer of hyaline cartilage. Osteotomy of the condylar neck (condylotomy)

In 1947 Ward and associatesSo noted that persistent joint pain was relieved in those persons who subsequently suffered fracture of the involved condylar neck. On the basis of these observations, he devised the technique of condylotomy which he described in 1961.j’ This operation is reserved for those cases of internal TMJ derangement that fail to respond to conservative therapy and show little or no radiographic evidence of joint disease. Condylotomy is usually performed as a blind technique in which the condylar neck is divided with a Gigli saw. Although few complications have been reported with “blind” condylotomy, Jamesj2 advo-

Fig. 9. Fibrous disk has been repositioned posteriorly

and sutured to the lateral aspect of the articular capsule.

cates the performance of this procedure through an open preauricular approach in order to have visual control over the position of the condylar fragment and to minimize the danger of severing the facial nerve and/or internal maxillary artery, which are hazards that have a greater likelihood of occurrence when the blind technique is used. Extreme care is taken during this procedure to preserve the integrity of the lateral periosteum overlying the condylar neck in order to reduce the possibility of fracture dislocation of the condyle due to activity of the lateral pterygoid muscle. The rationale for this technique is based upon a favorable repositioning of the condylar head in the glenoid fossa produced by the pull of the lateral pterygoid muscle. 10,44The condylar head is slightly displaced in an anteromedial direction, and this presumably relieves the pressure of the condyle against the free nerve endings in the lower stratum of the bilaminar zone of the disk. This is another example of the principle of intracapsular decompres-

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Fig. 10. Diagram showing increased superior joint space after eminectomy and plication of fibrous disk directly to lateral aspectof capsule.

sion, achieved in this instance by altering the position rather than the size and shape (high condylectomy) of the mandibular condyle. The high success rates reported for condylotomy have made it the favored operation of many surgeons44.5’*53.54 for the treatment of intractable TMJ pain and dysfunction. Arthroplasty

and meniscal repositioning

In 1979, McCarty and Farrar34 described the rationale and technique of reconstructive arthroplasty and disk repositioning for internal derangements of the TMJ. Performed via a preauricular approach, the operation involves excision of a 3 or 4 mm section of bone from the posterosuperior surface of the condyle in order to create adequate space for repositioning of the disk; a 2 mm strip of herniated or redundant posterior attachment is then excised, lateral to medial, just behind the fibrous disk; the meniscus is then sutured to the posterior attachment in its proper relationship to the condyle. In effect, minimal condylectomy has been performed and intracapsular decompression has been achieved through creation of a larger inferior joint space. Excision of a strip of posterior attachment produces denervation of a portion of the neurovascular zone of the disk23 and may, in part, be responsible for the high success rates reported for this operation. The surgical technique of eminectomy and meniscorhaphy for internal derangements of the TMJ

The TMJ is approached through a modified preauricular incision that includes a 1-inch-long

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temporal component made at 45” to the zygomatic arch, from the superior auriculocutaneous junction. Injury to the facial nerve may be reduced or avoided by operating posterior to a line drawn from the ear lobe to the lateral canthus of the eye (Middleton’s line)5” (Fig. 4). The skin incision is carried through subcutaneous tissue and superficial fascia to the level of the superficial layer of temporal fascia (Fig. 5); blunt dissection proceeds downward in this plane to a point about 2.0 cm above the zygomatic arch, where the temporal fascia splits; the skin flap is sutured forward at this stage. In order to minimize trauma to the temporal and zygomatic branches of the facial nerve, no attempt at further dissection of the superficial fascia from the temporal fascia is made beyond this point. At the root of the zygomatic arch, the superficial temporal fascia is incised 45’ upward and forward. Within this pocket, developed between the superficial and deep layers of temporal fascia, the periosteum investing the zygomatic arch is safely inciseds6 and retracted inferiorly, exposing the lateral aspect of the articular eminence and glenoid fossa. The dissection then proceeds along the anterior border of the ear, separating the tissues from the tragus cartilage. The tissue flap developed in this fashion contains the outer layer of temporal fascia and the superficial fascia enveloping the temporal outflow of the facial nerve. These tissues are retracted anteroinferiorly from the lateral aspect of the articular capsule. The superior joint space is entered with a small elevator, which is used to reflect the periosteum from the anterior slope, crest, and posterior slope of the articular eminence and the roof of the glenoid fossa. This superior joint space is quite tight, and occasionally considerable effort with a small, sharp periosteal elevator is required to separate the firmly adherent fibrous disk from the posterior slope and/or crest of the articular eminence. The entire mediolateral extent of the articular eminence is exposed and protected medially with a small, thin retractor that is placed in the anterior recess of the superior joint space, just above and in front of the upper surface of the fibrous disk. The eminence is scored horizontally with a 701 fissure bur (Fig. 6) and removed with a sharp, thin osteotome (Fig. 7); all peripheral bony irregularities are smoothed with a rosehead bur or a reciprocating bone file. After the eminectomy, the volume of the superior joint space is increased (Fig. 8); this permits free visual and manual access to the upper part of the entire disk, and a stretched posterior attachment is normally seen. The lower joint space is opened with an inverted L incision that is made through the posterolateral aspect of the capsule and approximately 2 mm below the lateral rim of the meniscus.

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11. Panorexfilm showingpneumatizedarticular eminence.

12. Panorex film showingdeepglenoidfossaand relatively steeparticular eminence.

The disk is then dissected free from the lateral pole of the condyle, and the articular surface of the condyle is inspected for any irregularities; these are smoothed with a rosehead bur or a diamond stone, or a minimal condylectomy (arthroplasty) is performed. The degree of disk displacement can be clearly demonstrated at this stage by manipulating the mandible. When the condyle is distracted inferiorly, the disk is mobilized posteriorly into its normal position. The lateral border of the disk is then secured to the lateral aspect of the capsule with approximately five to six synthetic absorbable sutures (Vicryl) that are placed 2 to 3 mm apart (Figs. 9 and 10). The lower joint space is sealed by closure of the vertical incision in the capsule. The security of the suture line is then tested by opening and closing the mandible. The upper joint space is closed by suturing the obliquely incised superficial temporal fascia that is lined in its lower aspect by the periosteum covering the zygomatic root and glenoid fossa. The wound is then sutured in layers, and a

pressure dressing is applied and maintained hours.

for 48

DISCUSSION

It would appear that surgical procedures that have been used successfully in treatment of the painful TMJ create and share the common effect of intracapsular decompression in one form or another. The success of surgical correction of internal TMJ derangements is directly related to an increase in intracapsular or intra-articular space by eminectomy, high condylectomy (arthroplasty), or a combination of both. This permits free, unrestricted movement of the anteriorly displaced meniscus and minimizes or eliminates pain by preventing compression, between condyle and eminence, of free nerve endings in the neurovascular zone of the posterior attachment. Any surgical procedure that involves meniscal repositioning only, without increased space above the condyle, may yield unsatisfactory results. The creation of adequate intra-articular space by eminecto-

248 Weinberg my and/or arthroplasty may, in fact, obviate the need for meniscal repositioning; Irby’s’O excellent results with eminectomy alone would appear to support this view. In addition, a large percentage of patients who experienced permanent relief of TMJ symptoms following high condylectomy or condylotomy alone must assuredly have suffered from some degree of undiagnosed internal derangement (anterior meniscal displacement). From a physio-anatomic standpoint, however, it is prudent to attempt to re-establish normal structural relationships by repositioning the disk. While excision and tightening of a portion of the posterior attachment (meniscoplasty) effectively repositions the disk34 and contributes to pain reduction by partial denervation of the neurovascular zone, the unnecessary technical difficulty encountered with this procedure has led to the simpler and equally effective technique of meniscal repositioning by direct suturing of the fibrous disk to the lateral wall of the capsule (meniscorhaphy). Although arthroplasty (minimal condylectomy condyloplasty) is indicated and desirable in cases of internal derangement characterized by erosive and/ or proliferative changes in the condylar head,4s the removal of even the smallest portion of a normalappearing condyle is unwarranted. Excision of the articular eminence effectively increases intracapsular space without altering the integrity of a structure as vital to normal joint function as the mandibular condyle. The resulting increased magnitude of the superior joint space permits free, unrestricted meniscal function,33 which is the essence of successful surgery for correction of internal TMJ derangements. So long as the nonmobile articular eminence remains intact, it affords an unyielding anterior physical block to unobstructed meniscal activity. While a loss of condylar guidance is the expected result of eminectomy, clinically, the joint remains remarkably stable, without any gross deficits in occlusal or masticatory efficiency. Because of the genuine danger of intracranial infection and/or hemorrhage, radiographic evidence. of a pneumatized or vascularized eminence (Fig. 11) constitutes an obvious contraindication to eminectomy.57,

58

Of interest is the fact that nineteen of the thirtythree patients operated on (57%) had Class II malocclusions, characterized by deep overbite, a deep glenoid fossa, and a relatively steep articular eminence (Fig. 12). This particular anatomic arrangement may partially contribute to the restriction of smooth condylar-meniscal translation.

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SUMMARY AND CONClUSlONS

During the past 44 months, forty eminectomies and meniscorhaphies have been performed on patients with internal derangements of the TMJ. Seven (21%) of the thirty-three patients operated on had bilateral surgery. Of the twenty-seven patients (thirty sides) who were examined at least 6 months postoperatively, 88.8% felt considerably better, 7.5% felt marginally better, and 3.7% felt worse. The rationale for this operation and the surgical technique have been described. Clinical experience with eminectomy and meniscorhaphy shows this to be an effective, uncomplicated, and physiologically sound procedure when surgical treatment is warranted for patients with internal derangements of the TMJ. REFERENCES I. Myrhaug H: A new method of operation for habitual dislocation of the mandible; review of former methods of treatment. Acta Odontol Stand 9: 247, I95 I. 2. Irby WB: Surgical correction of chronic dislocation of the tempotomandibular joint not responsive to conservative therapy. J Oral Surg 15: 307, 1957. 3. Hale RH: Treatment of recurrent dislocation of the mandible. J Oral Surg 30: 527, 1972. 4. Westwood RM, Fox CL, Tilson HB: Eminectomy for the treatment of recurrent temporomandibular joint dislocation. J Oral Surg 33: 774, 1975. 5. Cherry CQ, Frew AL: Bilateral reductions of articular eminence for chronic dislocation; review of eight cases. J Oral Surg 35: 598, 1977. 6. Sanders B, et al: Anatomic, radiographic and clinical evaluation of temporomandibular articular eminence reduction as a treatment for recurrent dislocation and chronic subluxation. Ann Dent 37: 33, 1978. 1. Sanders B. et al: An evaluation of temporomandibular eminence reduction as a treatment for recurrent dislocation and chronic subluxation: the potential benefits versus the anatomical hazard. Oral Health 70: 30, 1980. 8. Baumstark RJ. et al: A simple method of eminoplasty for correction of recurrent dislocation of the mandible. J Oral Surg 35: 75, 1977. 9. Lovely FW. Copeland RA: Reduction eminoplasty for chronic recurrent luxation of the temporomandibular joint. J Can Dent ASSOC 3: 179, 1981. IO. lrby WB: Surgery of the temporomandibular joint. In Irby WB (editor): Current advances in oral surgery, St. Louis, 1974, The C.V. Mosby Company, p. 189. I I. Wilkes CH: Arthrography of the temporomandibular joint in patients with the TMJ pain--dysfunction syndrome. Minn Med 61: 645, 1978. 12. Katzberg RW, et al: Arthrotomography of the temporomandibular joint: new technique and preliminary observations. Am J Roentgen01 161: 100, 1979. 13. Dolwick MF, ct al: Arthrotomographic evaluation of the temporomandibular joint. J Oral Surg 37: 793, 1979. 14. Farrar WB, McCarty WL: Inferior joint space arthrography and characteristics of the condylar paths in internal derangements of the TMJ. J Prosthet Dent 41: 548, 1979. 15. Blaschke DD, Solberg WK, Sanders B: Arthrography of the temporomandibular joint: review of current status. J Am Dent Assoc 100: 388, 1980. 16. Norgaard F: Arthrography of the mandibular joint. Acta radio1 25: 679, 1944.

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17. Campbell W: Clinical radiological investigations of the mandibular joints. Br J Radio1 38: 401, 1965. 18. Toiler PA: Opaque arthrography of the temporomandibular joint. Int J Oral Surg 3: 17, 1974. 19. Bellinger DH: Present status of arthrosis of the temporomandibular joint. J Oral Surg 6: 9-16, 1948. 20. Markowitz HA, Gerry RC: Temporomandibular joint disease. ORAL SURG 2: 1309, 1337, 1949. 21. Orban BJ: Oral histology and embryology, ed. 4, St. Louis, 1957, The C.V. Mosby Company. 22. Rees LA: The structure and function of the mandibular joint. Br Dent J 96: 125-133, 1954. 23. Dixon AD: Structure and functional significance of the intra-articular disc of the human temporomandibular joint. ORAL SURC 15: 48-61,

1962.

24. Pinto OF: A new structure related to the temporomandibular joint and middle ear. J Prosthet Dent It: 95, 1962. 25. Thilander B: Innervation of the temporomandibular joint capsule in man. Umea, Sweden, 1961, Transactions of the Royal School of Dentistry, Stockholm. 26. Klineberg I: Structure and function of temporomandibular joint innervation. Ann R Coil Surg Engl 49: 268, 1971. 27. Griffin CJ, Hawthorn R, Harris R: Anatomy and histology of the human temporomandibular joint. Monogr Oral Sci 4: 1, 1975. 28. Kawamura Y: Neurophysiology. In Sarnat BG, Laskin DM (editors): The temporomandibular joint, ed. 3, Springfield, Ill., 1980, Charles C Thomas, Publisher, p. 115. 29. Wheelock FM, Mercuri LG: A histological study of elastic tissue in the posterior attachment of the meniscus (abstract), 63rd annual scientific session, American Association of Oral and Maxillofacial Surgeons, Washington, D.C., September, 1981. 30. Storey AT: Controversies related to temporomandibular joint function and dysfunction. In Zarb GA, Carlsen GE (editors): Temporomandibular joint function and dysfunction, St. Louis, 1979, The C.V. Mosby Company, p. 436. 31. Porter MR: The attachment of the lateral pterygoid muscle to the meniscus. J Prosthet Dent 24: 555, 1970. 32. McNamara JA: The independent functions of the two heads of the lateral pterygoid muscle. Am J Anat 138: 197, 1973. 33. Mercuri LG, Campbell RL, Shamaskin RG: lntra-articular meniscus dysfunction surgery. ORAL SURG 54: 6 13, 1982. 34. McCartv WL. Farrar WB: Suraerv for internal deranaements of the temporomandibular-joint. J Prosthet Dent 42: 191, 1979. 35. Annandale T: On the displacement of the inter-articular carttlage of the lower jaw and its treatment by operation. Lancet, 1: 411, 1887. 36. Lanz A: Discitis mandibularis. Zentralbl Chir 9: 289, 1909. 37. Pringle J: Displacement of the mandibular meniscus and its treatment. Br J Surg 6: 385, 1918. 38. Wakely C: The causation and treatment of displaced mandibular cartilage. Lancet 2: 543, 1929.

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39. Boman K: Temporomandibular joint arthrosis and its treatment by extirpation of the disc. Acta Chir Scandinav Suppl 95: I, 1947. 40. Dingman RO, Moorman WC: Meniscectomy in treatment of lesions of the temporomandibular joint. J Oral Surg 9: 214, 1951. 41. Kiehn CL: Meniscectomy for internal derangements of the temporomandibular joint. Am J Surg 83: 364, 1952. 42. Rongetti JR: Meniscectomy, a new approach to the temporomandibular joint. Arch Otolaryngol 60: 566, 1954. 43. Silver CM, Simon SD: Meniscus injuries of the temporomandibular joint. J Bone Surg 38-A: 541, 1956. 44. Poswillo DE: Surgery of the temporomandibular joint. Oral Sci Rev 6: 87, 1974. 45. Jolly M: Condylectomy in the rat. Aust Dent J 6: 243, 1961. 46. Poswillo DE: The late effects of mandibular condylectomy. J Oral Surg 33: 500, 1972. 47. Ireland VE: The problem of the clicking jaw. Proc R Sot Med 44: 363, 1951. 48. Henny FA, Baldridge OL: Condylectomy for the persistently uainful temwromandibular ioint. J Oral Sum 15: 24. 1957. 49. bingman Rb, Grabb WC: Intracapsular tem&romandibular joint arthroplasty. Plast Reconstr Surg 38: 179, 1966. 50. Ward TG, Smith DC, Sommar M: Condylotomy for mandibular joint arthrosis. Br Dent J 103: 147, 1947. 51. Ward TG: Surgery of the mandibular joint. Ann R Coll Surg Engl 28: 139, 1961. 52. James P: Surgical treatment of mandibular joint disorders. Int J Oral Surg 7: 346, 1978. 53. Banks P, McKenzie I: Condylotomy. J Maxillofac Surg 3: 170, 1975. 54. Tasanen A, Konow L: Closed condylotomy in the treatment of idiopathic and traumatic pain/dysfunction syndrome of the temporomandibular joint. Int J Oral Surg 2: 102, 1973. 55. Middleton DS: Clinical approach to derangement of the mandibular joint. J R Colt Surg Edinb 17: 287-295, 1972. 56. Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17: 91, 1979-80. 57. Kulikowski BM, Schow SR, Kraut RA: Surgical management of a pneumatized articular eminence of the temporal bone. J Oral Maxillofac Surg 40: 311, 1982. 58. Tremble GE: Pneumatization of the temporal bone. Arch Otolaryngol 19: 172, 1934. Reprint

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Dr. Simon Weinberg The Doctors Hospital Medical Centre Suite 301 25 Brunswick Ave. Toronto, Ontario M5S 2L9, Canada