Surgery of the temporomandibular joint. II. Microsurgery

Surgery of the temporomandibular Microsurgery Keith L. Kreutziger, DEPARTMENT FOUNDATION

D.D.S.,

OF OTOLARYNGOLOGY,

joint. II.

M.D., New Orleans, La. OCHSNER

CLINIC

AND

THE

ALTON

OCHSNER

MEDICAL

The operating microscope has revolutionized many surgical procedures. Pioneering microtechniques for exploring and reconstructing the temporomandibular joint have been modified. The preauricular, endaural, and postauricular incisions may be used for approaching the temporomandibular joint in microsurgery procedures. Determinations of pathologic conditions and observations of temporomandibular joint function-dysfunction are dramatic and rewarding. Precision surgery using microinstruments, microneedles,microdrills, bipolar cautery, and the laser allows accuracy of technique that previously was impossible. Representative case presentations illustrate patient treatment, surgical incision, microsurgical technique employed, and clinical results obtained. (ORAL SURG. 58~647-655, 1984)

M

icrosurgery is an evolving, expanding field that has revolutionized many surgical procedures. The operating microscope was first introduced into medicine in the ‘field of otolaryngology by Maier and Lion’ in experimental animals and by Nylen* in human patients. Perritt3 recorded microsurgical techniques related to ophthalmology. Kurze4 subsequently began revolutionizing techniques in the field of neurosurgery by the use of microsurgery. This article describes the microsurgical approaches to the temporomandibular joint (TMJ) and the microtechniques used. Microsurgical techniques are applied to all intracapsular derangements of the TMJ. Such conditions include congenital conditions, trauma, hypomobility syndromes, arthritic conditions,neoplasms, and a host of miscellaneous diseases.5 Temporomandibular degenerative joint disease (TDJD),S*6 internal derangement of the TMJ,’ and traumatic disorders commonly result in afflictions amenable to microsurgical techniques. Internal derangements of the TMJ are common. The anteriorly displaced meniscus with permanent anterior position usually is manifest by decreased jaw opening, pain, myofascial discomfort, headaches, opening and closing joint sounds, and referred pain to the ear. With severe limitations of Read in part before the American Academy of Facial Plastic and Reconstructive Surgery, New Orleans, La., Sept. 19, 1981, and at the thirty-fourth annual meeting of the Southeastern Society of Oral and Maxillofacial Surgeons, Palm Beach, Fla., May 1, 1983.

movement, the meniscus is in a “closed-lock” position and a joint click no longer exists. Meniscus perforation, rupture of meniscus attachment, and herniated meniscus occur. Traumatic intracapsular injuries include hemarthrosis, fractures of the bony components (mandibular condyle and glenoid fossa), and traumatic injuries of the meniscus, capsule, and temporomandibular ligament. In the majority of TMJ disorders, conservative therapy will relieve symptoms. Conservative therapeutic measures vary according to the pathologic condition encounterer16 Surgical procedures are performed when conservative measures have failed, with symptoms that are persistent and intolerable, or when disease amenable to surgical correction has been diagnosed. Roentgenographic evaluation is essential in the preoperative studies. Transparietal TMJ films in the open and closed positions are screening roentgenograms. Polytomography is used when bony degenerative changes are suspected. If a degenerative joint is found and surgical intervention is indicated, an arthrogram, a more invasive procedure, is not performed. Microsurgical procedures will lead to a diagnosis of a pathologic internal derangement condition. Arthrography, cinefluorography,9 and arthrocinefluorography’O are necessary for an accurate diagnosis of internal derangement of the meniscus. Modifications of dynamic arthrocinefluorography, with video recording, allow evaluation of the TMJ in functional movements, result in the most 647

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-

Fig. 1. monitor position attached

A, Photograph of operating room showing surgical team with surgeon using microscope and placed for easy visualization. B, Schematic drawing showing operating room with appropriate of equipment and ancillary help. C, Photograph of operating microscope with 35 mm camera to the left and the video recorder attached to the right of the split beam attachments.

rewarding diagnostic findings, and replace static arthrography. Meniscus movements and anterior

displacements are readily observable. Therefore, dynamic arthrocinefiuorography is indicated when internal derangement is highly suspected as the only pathologic condition present, when conservative treatments have failed, when degenerative joint changes were not seen on polytomographs, and when surgical procedures are being contemplated. With improving techniques, computed tomography (CT scan) of the TMJ may be used to demonstrate the position of the meniscus. MATERIALS

AND METHODS

Microsurgery with supplemental technology requires increased personnel and a large operating room. An operating microscope is required, with a monitor placed so that the entire surgical team can visualize the procedure (Fig. 1, A). It is particularly

rewarding in the teaching of surgical technique as well as for recording videotapes. Equipment used (microscope, CO, laser, video recorder and monitor, bipolar cautery, and heart monitor) as well as the surgical technicians, circulating nurse, anesthesiologist and sterile surgical trays and tables must be arranged in appropriate positions to allow maximum use and availability (Fig. 1, B). The operative microscope* used in the procedures performed has the following specifications: A lens with 250 mm objective (objective focal length) is used for proper working distance. An f-125 inclined binocular tube allows a comfortable working position. The eyepiece has a power of 12.5,~ with a cross hatch on one side, allowing accurate focusing of a camera. An optical beam splitter with threaded attachments on each side gives the capability of *Zeiss,

OPMI-1,

Carl

Zeiss, Oberkochen,

West Germany

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Volume 58 Number 6

mounting an array of accessories for observation and documentation. A high-performance coaxial illuminator gives excellent light conditions. An automatic motorized zoom lens with motorized focus drive allows easy change of power from 2.5X to 15.6X. Ancillary equipment, which may be attached in any two combinations to the beams splitter, includes the 35 mm camera, the movie camera, the video tape and monitor, and the side arm (Fig. 1, C). The side arm, when attached to the beam splitter, allows one assistant to view the operation monocularly through the eyepiece. The CO, laser may also be attached to the microscope, expanding further the range of technology available as well as increasing the accuracy of surgery. Thus, a great deal of versatility exists, and the equipment used may be tailored to the needs of each specific operation. SURGICAL

TECHNIQUES

AND INCISIONS

General anesthesia via nasotracheal intubation allows freedom for complete manipulation of the jaw during microsurgical evaluation of internal joint function. The patient’s hair is shaved carefully from the temporal fossa 2 cm superior and posterior to the ear. A medium or large bite-block may be placed between the maxillary and mandibular dentitions to immobilize the mandible and to move the mandibular condyle to a position more anterior and lateral to facilitate the surgical approach. Selection of the surgical incision is made according to the criteria outlined in Part I of this article. Once the incision has been selected and dissection has isolated the temporomandibular ligament and capsule, the operating microscope is moved into position for the microsurgical procedures. MICROSURGICAL

PROCEDURES

Microsurgical procedures are preformed to the temporomandibular ligament-capsule, the meniscus, and internal joint procedures. The parotidoemasseteric fascia is elevated with the skin incision flap as described in Part 1. (Previously, the parotideomasseteric fascia was elevated as a separate anteriorly based flap as described in a previous publication.‘l This eliminates a tedious flap elevation and further protects the facial nerve branches within the fasciato-skin flap of the incision. Incisions are made to develop a posteriorly based capsule-temporomandibular ligament flap (Fig. 2). Three incisions are made in sequence-superior horizontal curvilinear, anterior vertical, and inferior horizontal. First, the superior horizontal curvilinear incision is made through the temporomandibular ligament-

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649

Fig. 2. Anatomic drawing showing the zygomatic arch (Z), TMJ capsule (JC), and TMJ ligament (L). The posteriorly based TMJ capsule-ligament flap is outlined with broken line.

capsule from anterior to posterior. Incision into the joint cavity begins anteriorly with release of synovial fluid with entrance into the joint cavity. A microduck-billed elevator is placed into the superior joint cavity, elevating the capsule laterally. This protects the internal joint and permits completion of the incision to its posterior extent. Second, an incision at the anterior extent of the capsule is carried inferiorly to its attachment to the condyle neck. Third, the inferior capsular attachment to the condylar neck is released, allowing an envelope flap to be reflected posteriorly (Fig. 3, A, flap A). This allows inspection of the superior joint cavity, the superior surface of the meniscus, and the glenoid fossa (Fig. 3, B). Manipulation of the mandible in dynamic movements and in static open and closed positions allows inspection of the meniscus and its attachments during function. The inferior joint space is explored through a lateral meniscus incision (incision delineated in Fig. 3, A). Immediately superior and lateral to the midline of the lateral pole of the mandibular condyle, a perforating incision of the meniscus into the inferior joint cavity is made with release of synovial fluid. The micro-duck-billed elevator or nerve hook is placed into the inferior joint cavity to protect the articular surface of the mandibular condyle. The lateral meniscus is lifted laterally as the incision is extended. Anterior extension follows a downward curve to the anterior meniscus attachment. Posterior extension curves to the loose posterior meniscus attachment of the bilaminar zone. The flap is

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Fig. 3. A, Anatomic drawingshowingzygomatic arch (Z), posteriorlyreflectedcapsule-temporomandibular ligamentflap (A) exposingsuperiorjoint cavity (SC) and meniscuscap (M). Dashedline outlineslimited meniscusincision.Dotted and dashedline outlinesadditional incisionsfor extendedexposure.B, Clinical photographshowingprobein posterioraspectof superiorjoint cavity, superiorjoint cavity (SC), meniscus cap (M), and posteriorly basedTMJ capsule-ligamentflap (A).

reflected inferiorly, exposing the inferior joint cavity and mandibular condyle articular surface with limited exposure (Fig. 4, A, flap B). Inspection of the inferior joint cavity of the TMJ during function in closed and open static positions is now performed. The articular surface of the condyle is inspected, and reinspection of the superior joint space, glenoid fossa, and anterior and posterior meniscus attachments is performed. When TDJD is severe, further exposure of the joint is necessary (Fig. 3, A, dot-dash incision line). An incision is made from the midline of the lateral meniscus incision and carried inferiorly to the midpoint of the meniscus attachment to the lateral condylar neck. The inferior attachment is released from the mandibular condyle anteriorly and posteriorly. Flaps are folded anteriorly and posteriorly, exposing the entire lateral pole of the condyle (Fig. 4, B, flaps C and C,). Technical procedures now vary, depending on the internal derangement observed on exploration. Such findings are correlated with polytomography and dynamic arthrocinefluorography of the TMJ. When the diagnosis is internal derangement of the TMJ with anterior displacement of the meniscus without degenerative changes of the articular surface of the mandibular condyle, the meniscus is posteriorly repositioned. The mandibular condyle is displaced inferiorly with the jaw open maximally. An incision

is made from lateral to medial just anterior to the bilaminar zone. Traction sutures are placed to the meniscus immediately anterior to the incision. With the mandible in the resting position with an incisal freeway space of 2 to 3 mm, the meniscus is repositioned posteriorly and laterally. The meniscus is held in this position while functional movements of the mandible are performed. This determines the degree of anterior displacement and the amount of posterior resection of the meniscus. The meniscus is marked and resected from lateral to medial with a microblade, scissors (Fig. 5, A, label E), or the CO, laser. The CO* laser is particularly suitable for sectioning the meniscus or in dissection of. the bilaminar zone. This results in a decrease in bleeding and accurate resection. Adhesions of the meniscus may also be released with laser energy. Intermittent or continued bursts of laser energy are used. Microtechniques are used to suture the meniscus posteriorly with synthetic permanent suture material. If the posterior resection of the meniscus is not indicated, posterior plication of the meniscus may be performed. If degenerative changes with spurs and irregularity of the articular surface of the condyle are present, they may be removed and the surface smoothed with microinstruments and microdrill. If severe degenerative changes are present, a high condylectomy is performed with removal of the

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articular surface of the mandibular condyle (Fig. 5, A and B). The articular surface is sectioned from lateral to medial with a microdrill. A small medial bone fragment is left intact to protect vital structures deep to the medial condyle pole. The medial bone is then fractured by placing a periosteal elevator into the ostectomy and twisting the instrument. The residual attachment of the superior belly of the lateral pterygoid muscle is dissected free, and the articular surface is removed from the surgical site. The meniscus is left intact to separate the glenoid fossa from the sectioned condyle. In addition, the meniscus helps to absorb functional trauma and to maintain vertical height. If removal of extensive vertical dimension is necessary, an implant of silicone is wired to the recontoured condyle. If a posterior repositioning of the mensicus is indicated, the previously described techniques are now performed (Fig. 5, A, label E). Closure is performed in reverse order. The lateral meniscus flaps are sutured into anatomic position (Fig. 6, A). The capsule-temporomandibular ligament flap is returned to its anatomic position and sutured securely (Fig. 6, B). The self-retaining retractor is released, and the ear and skin flap with the parotideomasseteric fascia as its deepest layer is placed into anatomic position. The deep tissues immediately surrounding the crosscut skin of the EAC are sutured with four to six circumferential sutures as the ear flap is returned posteriorly to its previous position. The postauricular incision is closed with standard techniques. If the endaural or preauricular incision is employed, the skin-fascia flap (temporal fascia-periosteum of the zygomatic arch-parotideomasseteric fascia) is returned to its anatomic position and closed with standard techniques. CASE CASE

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REPORTS 1

A 29-year-old distraught womancomplainedof severe painand lossof function of the right TMJ, accompaniedby excruciating temporal headache. Symptoms had been presentfor more than 10 years and had been gradually increasingin severity, frequency, and duration. Severity had increaseddramatically in the past 2 years. Other initial symptomsincludedjoint soundsof the right TMJ, occasionalpain to the contralateralTMJ, right retrobulbar pain, occasionalblurred vision associatedwith the headaches,edemaof the right upperandlower eyelids,burning sensationto the scalp,right mastoidtip, and cortex, pain, decreasedhearing in the right ear, and a burning of the right sideof the tongue.The patient had receivednumerous treatments. Medical treatment included analgesics, narcotics, muscle relaxants, tranquilizers, aspirin, and steroids.Dental managementincludedocclusalequilibrations on four occasions and four occlusaland repositioning

G

Fig. 4. A, Anatomic drawing illustrating limited meniscus incision completedand flap (B) reflected inferiorly, exposinginferior joint cavity (K) and articular surfaceof mandibularcondyle (MC). Zygomatic arch (Z), superior joint cavity (SC), meniscus (M). and posterior capsuletemporomandibularligament flap (A) are identified. B, Anatomic drawing showingextendedexposureof inferior joint cavity (ZC)and mandibularcondyle(MC) with lateral meniscusflapsreflectedanteriorly (C,) and posteriorly(C). Zygomatic arch (Z), superiorjoint cavity (SC), meniscus (M), and posterior capsule-temporomandibular ligament flap (A) are identified.

splintsduringa lo-year period,whichonly seemedto cause an increasein symptoms. InitiaI examination discloseddiscoordinatefunctional movementsof the mandiblewith an openingof 12 mm betweenthe incisaledgesof the maxillary and mandibular centralincisors.A ClassI functional occlusionwaspresent. Palpationdisclosedtenderness to the right trapeziusmuscle and right TMJ. Stethoscopeauscultationof the right TMJ revealedan painful openingsnapwith crepitusand an occasionalreciprocalclick in the left TMJ. Examination disclosednormalaudiologictest resultsand a normal

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5. A, Anatomic drawing showinghigh condylectomy(F) completedand posteriormeniscusresection (5) completedfor posterolateralrepositioning.Zygomatic arch (Zj. superiorjoint cavity (SC), inferior joint cavity (ICI. meniscus(M), posteriorcapsule-temporomandibularligamentflap (A/ and anterior (C,) and posterior (Cl meniscusflaps are identified. B, Microclinical photograph showing high condylectomy completed(F). Zygomatic arch (Z], meniscus(M), and temporalisfat (5) are identified. Fig.

panoramicroentgenogram;a neurologyconsultationidentified no neurologicdisease;and a psychiatric consultation describedthe developmentof a life style surroundingand drawing attention to the pain. Dynamic arthrocinefluorographicexamination of the right TMJ demonstrateda pronouncedsnapon translation with an anteriorly displacedmeniscus.A microsurgical arthroplasty of the right TMJ identified internal derangement with an anteriorly displacedmeniscusand rupture of the posteriormeniscus attachment.In addition, the central inferior surfaceof the meniscusshoweddegenerationwith hard plaquing.Posteriorresectionwith posterolateralrepositioning of the meniscuscorrected the pathologiccondition. Thirty months postoperatively,the patient has an incisalopeningof 42 mm, hasno pain upon mastication, and doesnot experienceheadaches; other associated symptomshave shownresolution. CASE 2

A 34-year-oldwomanwasseeninitially with pain and poppingto the TMJs with difficulty masticating.A complex history showedthat the patient’ssymptomsbegana year earlier with locking of the jaw after a wide opening, causingsevereleft TMJ pain. Manipulation of the jaw, medicaltreatment,occlusalequilibration,anduseof a bite splint partially resolvedthe symptoms.Evolution of symptoms disclosedsevere left TMJ pain and dysfunction followed by severeright TMJ pain. The patient alsohad headachesand true vertigo and adopted a life style revolving around her pain complex. Previous therapy consistedof analgesics(including narcotics,tranquilizers, musclerelaxants, oral steroids,and steroid joint injections), multiple occlusalequilibrations, use of two bite

planes,and an arthrogram. The arthrogram showeda perforationof the right meniscus.The patient alsounderwent bilateral mandibularcoronoidectomies. Initial examination showedtendernessto palpation of the bilateral temporalis,masseter,and external pterygoid muscles.Thejaw openingwas21 mmat the central incisor edges,with painful openingsnapon auscultation.Scarring waspresentintraorally on the coronoidprocesses. Laboratory tests showednormal results of a twelvefactor automatedchemicalanalysis,thyroid function tests, 2-hour postprandialglucose-tolerance level, and serologic study. Normal audiologytest resultsincludedpure tones, speechreceptionthreshold,discrimination,tympanogram, and stapedial reflexes. Electronystagmographyshowed nonspecificchanges.Internal auditory canal roentgenogramswere normal. Polytomographicexaminationof the TMJs showedsevere degenerativechangesof the left condyle with osteophyteformation and flattening of the condyle and narrowedjoint space.The right joint had moderatedegenerativechanges.The dynamic cinefluorostopic arthrogramshoweda perforationof the left meniscus and a right anteriorly displacedmeniscus. Neurologic and psychiatric consultations indicated, respectively, muscle-contracture headachesand stress involvement centeredaround the chronicity of the pain symptoms. Bilateral microsurgicalTMJ arthroplastieswere performedwith a left high condylectomyanda right posterior repositioningand plication of the meniscus.Findings at surgery showeda left irregular, flattened, degenerative articular surfaceof the condyle,osteophyteformation, and anterior lipping. There was a microperforation of the meniscuswith granulation tissue.The articular surfaceof

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7. Static roentgenographic view during arthrography in the wide-open position showing a peaking or tenting (arrow) of the radiopaquematerial signifying a tear in the meniscus posteriorattachmentsof the bilaminarzone.The arrow demonstratesthe tenting. Fig.

Fig. 6. A, Anatomic drawings showing surgical closures of anterior (C,) and posterior (C) meniscus flaps and meniscus posteriorly repositioned (E). Zygomatic arch (Z), superior joint cavity (SC), anterior meniscus (M), and posteriorly reflected capsule-temporomandibular ligament flap (A) are identified. B, Anatomic drawing showing surgical closure of the posteriorly based capsule-temporomandibular ligament flap (A).

the right condyle had a small degree of irregularity. The meniscus was completely dislocated anteriorly, with fibrosis preventing its posterior movement. Twenty-seven months postoperatively the patient has an incisal opening of 44 mm with normal masticatory function and no TMJ pain. CASE

3

A fascinating 46-year-old woman, on her initial visit, reported an I-year history of chronic pain. Her complaints included an 8-year history of pain in the left arm with aching and numbness. She also had pain in the rib cage as well as multiple joint and back pain. The most severe symptoms were referred to the TMJ’s. For 7 years she had

had bilateral TMJ edemawith temporal pain and pain during mastication.There was bilateral snappingof the TMJs on opening,with occasionalexcruciating pain. The patient relatedmultiple episodes of “lockjaw,” with severe restriction of openingresulting in restriction of diet and weight loss. She complainedof temporal and masseter musclepain. She alsoexperienceda sensationof fluid in both ears,with a poppingsensationbilaterally. In addition, the patient complainedof a throbbing headachewhich startedin the middleof the lowerback and radiatedup the spineto the napeof the neck and around the back of the head to the TMJs. She complained of a decreasein memorywhich had becomeworseover the previousseveral years, menstrual irregularity, intermittent breast pain, nasal congestion,postnasaldrip, and occasionalsore throat. She had a history of a ruptured cervical disk, and had undergonea cervical fusion5 yearspreviously. The patient had undergonemultiple dental examinationsandtreatments,includingmultipleocclusalequilibrations, steroid and anestheticjoint injections, and four occlusalsplintson different occasionswithout relief. Multiple radiographs,had been taken which included panoramic, transparietalviews, polytomography,and arthrograms.Medical treatment includedanalgesics,narcotics, muscle relaxants, tranquilizers, aspirin, and steroids. Presentmedicationswere tolmetin sodiumand methocarbamol. Initial head, neck, and oral examinationsrevealedthe following: The ear and noseexamination findings were normal.The patient had tenderness to the bilateral temporalis, masseter,and lateral pterygoid muscles.There wasa deviation of the mandibleto the right, with an incisal openingof 26 mm and bilateral snappingwith severepain. The patient limited the openingof the jaw to approximately 10mmto avoid the pain. Lateral andendauralpalpation

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Kreutziger

of the TMJs revealedopeningsnapswith painandcrepitus. The remainingexaminationfindingswere unremarkable. Roentgenographicwork-up consistedof bilateral TMJ polydirectionaltomography,which showedbilateral anteromedial spurring with closureof the joint spaces.Arthrography of the right TMJ showeda tenting or peaking of the inferior joint spacewhich progressed in severity with wide opening.This wasthought to be a disruption of the bilaminar attachment of the meniscus(Fig. 7). There appearedto be an anterior displacementwith capture of the meniscus.Arthrography of the left TMJ showed anterior displacementof the meniscuswith capture. Subspecialtyconsultationsrevealedinterestingimpressions.The neurologyconsultationrevealedthat the patient hada mild residualcervical radiculopathy.The rheumatology evaluationindicatedthat the patient had psychogenic rheumatoiddisease.The psychiatricconsultationrevealed the probability of an underlying characterologicdisorder. Psychologicaltestingshoweda valid MinnesotaMultiphasic Personality Inventory with scoresindicating a high probability of functional etiology of the multiple pain complaints.The scoreswerevery high on both the hysteria andthe hypochondriasis scales.The configurationthat the patient producedwassimilar to that producedby hysterics. Laboratory tests showednormal results of a twelvefactors automated chemical analysis, thyroid-function tests, erythrocyte sedimentation rate, complete blood count, follicle-stimulating hormone,antinuclear antibody titer, rheumatoid factor, creatinine phosphokinaseand creatininephosphokinase isoenzymes, bands,and serology. The triglyceride level waselevated.The urinalysisfindings were normal. The preoperativediagnosisof the temporomandibulardisorderwas bilateral degenerativejoint diseasewith bilateral anterior displacementand capture of the meniscusand a tear in the right posteriorattachment of the bilaminar zone. Bilateral microsurgicalarthroplastieswereperformed.Findingsat surgeryverified the above findings,with a most interesting fibrosisof the meniscus anteriorly and a tear in the posteriormeniscusattachment. Bilateral high condylectomieswere performedwith posterior repositioningof the meniscus.Histopathologicslides showedadvanceddegenerativejoint diseaseof both articular surfaces.Postoperatively,the patient returned to normal TMJ function without pain. Nine monthsafter surgery shecomplainedof pain and swellingof both TMJs, which was diagnosedas myalgia. This resolvedin 3 to 4 days after treatment with 5 mg diazepamthree times a day, moistwarm compresses, and restriction of diet to soft and liquid foods.The patient then beganto have a gradual return of someof her somaticcomplaintsto other regions of the body. CONCLUSION

The microsurgical approach to the TMJ

is an exciting new horizon in the surgical management of temporomandibular disorders. The postauricular approach allows adequate exposure, with a decreased

Oral Surg. December. 1984

occurrence of injury to the facial nerve and excellent cosmetic results. The preauricular and endaural incisions may also be employed with the indications, advantages, and disadvantages outlined in Part I of this article. The operating microscope allows brilliant illumination with magnified vision. The function and pathologic conditions encountered are accurately evaluated and diagnosed. Microsurgery facilitates refinement of operations and innovation of new operations. Precision surgery allows gentle tissue manipulation, small incisions, meticulous hemostasis, and accurate removal of diseased tissue. Flap designs and incisions of the temporomandibular ligament, capsule, and meniscus are established in accordance with the requirements of regional anatomy and function. The parotideomasseteric fascia is elevated with the skin-fascia incision flap (postauricular, endaural, or preauricular) eliminating the previously anteriorly based flap. The incisions and flaps are designed to minimize cicatrix formation and adhesion of layers, providing more normal postsurgical anatomy and function of the joint. This design facilitates identification of the various levels of tissues to be sutured on closure. Supplemental technology also allows videotape recording, monitoring of the surgical procedure, and movie still photog-

raphy. The microscope with the monitor and videotape is placed so that the entire surgical team can visualize the procedure. The CO, laser may also be used in the bilaminar zone with complete control of hemostasisor in the wedge resection of the meniscus

with increasing accuracy medially. The representative cases illustrate the complexity of symptoms, evaluation, and management. Patients undergoing microsurgery show encouraging asymptomatic results. In particular in patients with internal derangements of the TMJ without bony degenerative changes findings can be observed dramatically with the microscope. Traditionally, surgical procedures have been withheld from these patients. Parts of this article, including Figs. 3, B and 5, B (American Medical Association),appearedin the Archives of Otolaryngology.” The author wishesto thank Kenneth A. Bell, M.D., Departmentof Radiology, OchsnerClinic, for his interpretation of the radiographs in the case reports. REFERENCES

1. Maier M, Lion H: Exper Nachweis d Enpolymfbewegung. Pfluegers Arch 187: 13, 192 1. 2. NylenCO:The microscope in auralsurgery: Its first use and later development. Acta Otolaryngol 16:(Suppl.):226-240, 1954.

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Volume 58 Number 6 3. Perritt RA: Recent advances in cornea1 surgery, (abstracted). Trans Am Acad Ophthalmol Otolaryngol 54: 428, 19491950. 4. Kurze T: Microtechniques in neurological surgery. In Clinical neurosurgery, Baltimore, 1964, Williams & Wilkins Company, vol. 2, pp. 129-137. 5. Kreutziger KL, Mahan PE: Temporomandibular degenerative joint disease. Part I. Anatomy, pathophysiology, and clinical description. ORAL SURG 40: 165-182, 1975. 6. Kreutziger KL, Mahan PE: Temporomandibular degenerative joint disease. Part 11. Diagnostic procedure and comprehensive management. ORAL SURG 40: 297-3 19, 1975. I. Bronstein SL, Tomasetti BJ, Ryan DE: Internal derangements of the temporomandibular joint: correlation of arthrography with surgical findings. J Oral Surg 39: 572-584, 1981.

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8. Ndgaard F: Temporomandibular arthrography, Copenhagen, 1974, E. Munksgaard, pp. 29-80. 9. Berry HM Jr: Cineradiographic observation of temporomandibular joint function. J Prosthet Dent 9: 21-33, 1959. 10. Murphy WA: Arthrography of the temporomandibular joint. Radio1 Clin North Am 19: 365-378, 1981. 11. Kreutziger KL: Microsurgical approach to the temporomandibular joint: a new horizon. Arch Otolaryngol 108: 422-428, 1982. Reprint

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Dr. Keith L. Kreutziger Ochsner Clinic 1514 Jefferson Highway New Orleans, LA 70121