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Intraoperative assessment of discal position using C-arm arthrography during arthroscopic surgery
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ences in range of motion between groups. Anterior open bites occurred only in bilateral implant cases, one Silastic of five cases (20%), and nine Proplast of 15 cases (60%). Responses to the patient questionnaire indicated no difference among the procedures in terms of postoperative pain level (mean, 2.6/10 with 0 = no pain), chewing ability (mean, 2.300 with 0 = no chewing difftculty), or patient satisfaction (mean. 7.9200 with 10 = very satisfied). Analysis of pre- and postoperative tomograms evaluated osseous changes and findings were categorized as no change, mild change (flattening only), moderate change (flattening with osteophyte or erosion), and severe change (overall loss of articular surface contour). No change was seen in 14 joints (10 D, one S, three P), mild change in 12 joints (five D, four S, three P), moderate change in 30 joints (four D, six S, 20 P), severe change in 37 joints (one D, 36 P). Corrective procedures have been required in 12 patients, all with Proplast implants. Ten patients had the implants removed for significant pain while two patients had staged removal of the implant and maxillary osteotomy to correct the developed anterior open bit. Conclusions: 1) All TMJ procedures demonstrated a potential for degenerative change. Those changes may not be expressed in terms of clinical performance or patient satisfaction; 2) Postoperative radiographic evaluation is essential for adequate assessment of the procedures; 3) In view of the severity of the postoperative radiographic changes in the presence of Proplast implants, close clinical and radiographic followup of Proplast patients is warranted. Intraoperative Assessment of Discal Position Using C-Arm Arthrography During Arthroscopic Surgery. Mark A. Piper, DMD, MD. 111 Second Avenue NE, Suite 1006, St. Petersburg, FL 33701 (Chuong R) Arthroscopic surgery is gaining acceptance as a surgical tool in those patients with temporomandibular joint (TMJ) internal discal displacement. Thus far, arthroscopy has been used primarily for diagnosis and for lysis and lavage of joint spaces. Reports of alleviation of joint symptoms have been made for the early follow-up of arthroscopic surgery. However, to date, no proof has been given as to whether arthroscopy actually improves discal position. This discussion presents one method of assessing intraoperative discal position during TMJ arthroscopic surgery. Using a sterilely draped cinefluoroscopic C-arm, it is possible to perform intraoperative inferior joint spare arthrography. After induction of general anesthesia, an inferior joint space arthrogram is obtained. Superior joint space arthroscopy for lysis and lavage of adhesions and for manipulation of discal tissue is then carried out. A repeat inferior joint space arthrogram is then performed immediately after arthroscopy to assess for any change in discal position. Thus far 16 joints with anteriorly displaced discs have been examined with intraoperative C-arm arthrography during arthroscopic surgery. One joint required an open technique prior to the postoperative arthrogram. Of the 15 remaining joints, one disc showed evidence of relocation from a subluxed to a normal position after arthroscopic surgery. Fourteen discs showed no evidence of improvement in discal position after arthroscopic surgery. From this study, it would appear that the surgical arthroscopic technique employed has minimal value in improving discal alignment. While the improvement in joint symptoms may be based upon factors other than discal realignment, it is perhaps more
important to observe the long-term results in those patients whose discs remain subluxed despite careful arthroscopic surgery. Furthermore, as arthroscopic surgery improves, intraoperative C-arm arthrography may prove to be invaluable in assessing those techniques that do modify discal positioning. Sternoclavicular Grafts for Temporomandibular Joint Reconstruction. Larry M. Wolford, DDS, Brian R. Smith, DDS. Baylor College of Dentistry. Department of Oral and Maxillofacial Surgery, 3302 Gaston Avenue, Dallas, TX 75246 Total reconstruction of the temporomandibular joint (TMJ) may be possible with sternoclavicular grafts. The medial clavicular head has similar anatomy, histology, and function to the mandibular condyle. This paper presents a new method of harvesting medial clavicular grafts and reports preliminary results on 21 patients. In this technique, the medial clavicular head and articular disc are hemisected with the superior portion removed to be used as the graft. The grafts are then placed through a preauricular and/or a submandibular approach and stabilized with bone screws. There were 15 female and six male patients who underwent this surgery with a total of 29 joints (13 unilateral and eight bilateral). Length of follow-up ranged from five to 15 months. Patient ages ranged from 6 to 42 years. Indications have included ankylosis (5), rheumatoid arthritis (2), condylar hyperplasia (l), severe growth disturbance secondary to condylar fracture (1), and severe condylar resorption secondary to prior proplast/teflon joint reconstruction (17). Presurgery, immediate postsurgery, and follow-up clinical, cephalometric, and panographic analyses of each case were done. Results: No grafts were lost to infection or resorption. Incisal openings at longest follow-up have ranged from 15 mm to 40 mm with an average 1.0. of 27 mm. One graft fractured but subsequently healed. There have been four clavicular fractures. Two patients developed a slight Class II tendency which may indicate some graft remodeling or resorption. Five patients continue to have moderate pain but two are significantly improved over the preoperative pain. Adhesions have been a common occurrence. Four patients have required additional surgery usually related to release of adhesions. Three other patients may require adhesion release in the future. The length of the study thus far does not allow an assessment of growth on the three young patients. It is concluded from this series that sternoclavicular grafts may be promising for TMJ reconstruction. However, we do not advocate the use of this technique until long-term follow-up evaluations are completed. Additional modifications of the techniques are being investigated and may improve the results. Autogenous Cartilage as an Interpositional Material Following Total Discectomy of the TMJ. Myron R. Tucker, DDS. University of North Carolina at Chapel Hill, School of Dentistry, Department of Oral and Maxillofacial Surgery, Chapel Hill, NC 27514 (Kennady MC) Temporomandibular joint (TMJ) discectomies have been performed when repair of the temporomandibular disc has not been possible. This has been accomplished using a variety of surgical techniques including no replacement, alloplastic implants, and homologous grafting materials. At this time no reported animal studies exist
ences in range of motion between groups. Anterior open bites occurred only in bilateral implant cases, one Silastic of five cases (20%), and nine Proplast of 15 cases (60%). Responses to the patient questionnaire indicated no difference among the procedures in terms of postoperative pain level (mean, 2.6/10 with 0 = no pain), chewing ability (mean, 2.300 with 0 = no chewing difftculty), or patient satisfaction (mean. 7.9200 with 10 = very satisfied). Analysis of pre- and postoperative tomograms evaluated osseous changes and findings were categorized as no change, mild change (flattening only), moderate change (flattening with osteophyte or erosion), and severe change (overall loss of articular surface contour). No change was seen in 14 joints (10 D, one S, three P), mild change in 12 joints (five D, four S, three P), moderate change in 30 joints (four D, six S, 20 P), severe change in 37 joints (one D, 36 P). Corrective procedures have been required in 12 patients, all with Proplast implants. Ten patients had the implants removed for significant pain while two patients had staged removal of the implant and maxillary osteotomy to correct the developed anterior open bit. Conclusions: 1) All TMJ procedures demonstrated a potential for degenerative change. Those changes may not be expressed in terms of clinical performance or patient satisfaction; 2) Postoperative radiographic evaluation is essential for adequate assessment of the procedures; 3) In view of the severity of the postoperative radiographic changes in the presence of Proplast implants, close clinical and radiographic followup of Proplast patients is warranted. Intraoperative Assessment of Discal Position Using C-Arm Arthrography During Arthroscopic Surgery. Mark A. Piper, DMD, MD. 111 Second Avenue NE, Suite 1006, St. Petersburg, FL 33701 (Chuong R) Arthroscopic surgery is gaining acceptance as a surgical tool in those patients with temporomandibular joint (TMJ) internal discal displacement. Thus far, arthroscopy has been used primarily for diagnosis and for lysis and lavage of joint spaces. Reports of alleviation of joint symptoms have been made for the early follow-up of arthroscopic surgery. However, to date, no proof has been given as to whether arthroscopy actually improves discal position. This discussion presents one method of assessing intraoperative discal position during TMJ arthroscopic surgery. Using a sterilely draped cinefluoroscopic C-arm, it is possible to perform intraoperative inferior joint spare arthrography. After induction of general anesthesia, an inferior joint space arthrogram is obtained. Superior joint space arthroscopy for lysis and lavage of adhesions and for manipulation of discal tissue is then carried out. A repeat inferior joint space arthrogram is then performed immediately after arthroscopy to assess for any change in discal position. Thus far 16 joints with anteriorly displaced discs have been examined with intraoperative C-arm arthrography during arthroscopic surgery. One joint required an open technique prior to the postoperative arthrogram. Of the 15 remaining joints, one disc showed evidence of relocation from a subluxed to a normal position after arthroscopic surgery. Fourteen discs showed no evidence of improvement in discal position after arthroscopic surgery. From this study, it would appear that the surgical arthroscopic technique employed has minimal value in improving discal alignment. While the improvement in joint symptoms may be based upon factors other than discal realignment, it is perhaps more
important to observe the long-term results in those patients whose discs remain subluxed despite careful arthroscopic surgery. Furthermore, as arthroscopic surgery improves, intraoperative C-arm arthrography may prove to be invaluable in assessing those techniques that do modify discal positioning. Sternoclavicular Grafts for Temporomandibular Joint Reconstruction. Larry M. Wolford, DDS, Brian R. Smith, DDS. Baylor College of Dentistry. Department of Oral and Maxillofacial Surgery, 3302 Gaston Avenue, Dallas, TX 75246 Total reconstruction of the temporomandibular joint (TMJ) may be possible with sternoclavicular grafts. The medial clavicular head has similar anatomy, histology, and function to the mandibular condyle. This paper presents a new method of harvesting medial clavicular grafts and reports preliminary results on 21 patients. In this technique, the medial clavicular head and articular disc are hemisected with the superior portion removed to be used as the graft. The grafts are then placed through a preauricular and/or a submandibular approach and stabilized with bone screws. There were 15 female and six male patients who underwent this surgery with a total of 29 joints (13 unilateral and eight bilateral). Length of follow-up ranged from five to 15 months. Patient ages ranged from 6 to 42 years. Indications have included ankylosis (5), rheumatoid arthritis (2), condylar hyperplasia (l), severe growth disturbance secondary to condylar fracture (1), and severe condylar resorption secondary to prior proplast/teflon joint reconstruction (17). Presurgery, immediate postsurgery, and follow-up clinical, cephalometric, and panographic analyses of each case were done. Results: No grafts were lost to infection or resorption. Incisal openings at longest follow-up have ranged from 15 mm to 40 mm with an average 1.0. of 27 mm. One graft fractured but subsequently healed. There have been four clavicular fractures. Two patients developed a slight Class II tendency which may indicate some graft remodeling or resorption. Five patients continue to have moderate pain but two are significantly improved over the preoperative pain. Adhesions have been a common occurrence. Four patients have required additional surgery usually related to release of adhesions. Three other patients may require adhesion release in the future. The length of the study thus far does not allow an assessment of growth on the three young patients. It is concluded from this series that sternoclavicular grafts may be promising for TMJ reconstruction. However, we do not advocate the use of this technique until long-term follow-up evaluations are completed. Additional modifications of the techniques are being investigated and may improve the results. Autogenous Cartilage as an Interpositional Material Following Total Discectomy of the TMJ. Myron R. Tucker, DDS. University of North Carolina at Chapel Hill, School of Dentistry, Department of Oral and Maxillofacial Surgery, Chapel Hill, NC 27514 (Kennady MC) Temporomandibular joint (TMJ) discectomies have been performed when repair of the temporomandibular disc has not been possible. This has been accomplished using a variety of surgical techniques including no replacement, alloplastic implants, and homologous grafting materials. At this time no reported animal studies exist