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Surgical operations on the mandibular joint with regard to the articular disc
ABSTRACTS
OF
CURRENT
1349
LITERATURE
was readily controlled with epinephrine. The pathologic report was as follows: The specimen consisted of a flat pinkish gray mass, 1.1 by 0.8 by 0.3 cm. in size. It was covered on one surface by a finely granular epithelium; the under surface had a smooth, glistening appearance. Microscopically The bone present was 4 mm. in diameter and yellowish white. it was found to be essentially normal cancelloux bone showing myelofibro.sis. On November 21, another specimen for biopsy was taken in a similar manner from the same turbinate bone near the middle portion. This specimen grossly consisted of four irregularly shaped yellowish white piece.s of osseous material. On section the material was yellowish white and of uniformly hard consistency, with the exception of a small amount of soft osseou,s tissue seen at the base of one piece. Microscopically the mucous membrane showed a chronic inflammatory reaction, and the osseous tissue showed myelofibrotic changes compatible with early fibrous dysplasia.” T. J. C.
DISEASES Surgical
OF THE
MANDIBULAR
Operations on the Mandibular Joint With Regard Trauner. Deut’sche. zahniirzt. Ztschr. 5: 5, 1950.
JOINT to the
Articular
Disc.
Richard
Due to the rare occurrence of hematogenic infections of the mandible and considering rheumatoid arthritis as one of the potential sources of this sort of lesions, with the exception of trauma, diseases of the temporomandibular joint are rather infrequent, The more often observed bony inflammatory processes of the mandible are many times of local character and might be traced back to cau’ses which originate from teeth and ears. A strong expression of warning is put forward by the author with respect to operative interventions in the temporomandibular region, as most of the lesions of that area, may they be traumatic or otherwise, might be successfully treated without surgery. Thus Hofer of. Vienna has often demonstrated the unneceesary extirpation of the fractured mandibular capitulum, or its repositioning by surgery. However, if conditions do require a recourse to surgery, the condyloid process of the mandible may be removed without seriously impeding the functional fitness of the jaw through that procedure. This experimental proof becomes more convincing if its simple articulation and the lack of a static load on it are considered. There might be other circumstances under which the surgical approach of the mandibular joint cavity is indicated, e.g., in the case of actinomycosis, or in empyema. While an operation in these cases might be considered as a decisive intervention quoad vitam due to existing possibilities of a meningeal encroachment, it is not always clear whether the application of surgery i.s the response to sometimes not too valid indications, as it may occur in many instances that the signs and symptoms of grave lesions of the mandibular joint are completely lacking and thus worthless in adopting an indication for any treatment. The actinomycosis of the temporomandibular articulation often resembles a harmlesslooking fistula, and the empyema, because of the joint capsule’s tightly structured tissue, does not reveal any fluctuating prominence. The chondromatosis might be classified with mandibular joint lesions, although its occurrence, characterized by intra-articular bodies freely diepemed within the area covered by the joint’s capsule, is seldom encountered. The most frequent disturbance of the mandibular joint is the cracking noise, at the opening of the mouth, although even in this case surgery is rarely indicated. There are two forms of the noise phenomenon. In one type the excessive forward thrusting of the mandibular capitulum on the articular tubercle results in a loud cracking noise (Axhaueen’s terminal This type of cracking noise does not cause any particular subjective cracking noise). inconvenience to the patient. A method surgery, described by Konjetzny, according to which the discus articularis is di’splaced and fixed in an anterior aspect to the joint cavity, would eliminate the disturbance. This surgical intervention is simple and as a rule withIn the second type the cracking noise is accompanied by pain and out complications.
1350
Qt~ARTER1,1’
I
OF
f,ITEIZ.\‘I’t
:KI’
trismus. The noise originates already at. the! lleg:inning 01’ the inouth opening if ill0 I& mm a priori does not exclude such a movcrnen 1. However. :III operation on the joint might be indicated only if no improvement in 1111, condition we*-~ ollsorved IIF :L i~onsr~rvative method of treatment exclusively. The estirpat,ion of the ;crt irular disk would remove the trouble. A quite different view should l,e :rdopted in eases in whit-h lesions of the t.emporomandibular joint led to an existing ank~losis. This comlllim tion relatively often in childhood. Following operations in the ear, or as x result of scaarlet fever, anal :~lso as a posttyphoid lesion, often mandibular joint complications arise with an ankylosin of the temporoThe picture of ihe disease would 1~~ further aggrava.ted by a mandibular articulation. developing or existing microgenia due to the disarranged course of mandibular growth. The operation previously consisted of t.he smoothing of the glenoid cavity and in tapering of the condyloid process. However, the author, as well as other workers (Konig and Dufourmentel) who have availed themselrrs of this method of mandibular joint, surgery, has observed a regular recidivation of the preoperative lesion. Four cases among thirteen patients operated upon are reported by the author in which t,he lesion relapsed in a period of one year, In nine patients from ten operated upon, the lesion relapsed in ankylosis five years after the operation. It might be pointed out that at that time, in order to obtain a correction of these pathologic conditions, fa.sciae, musrles, Eden rubber were underlaid between the mandibular capitulum and the glenoid cavity. All these methods used and attempted by surgery have resulted in a failure. Today the picture of postoperative conditions is definitely better. Dufourmentel interlaces relatively great portions of cartilage taken from the ribs. The author uses cartilage from the ears which eovcrs the joint. cavity entirely. He emphasizes the advantages which derive from the use of the so-called activators designed and used according to the iunt,ructions given by Andresen. i\n applicator used postoperatively keeps the dental arches awa,v from each other. Topographically the articular disc lies horizontally between thr joint cavity of the temporal bone and the capitulum of the mandible. Through the disc the temporomandibular joint is divided into two parts. When the mandible moves in a forward direction the disc goes together with it by traction of the external pterygoid muscle. In the opening of the mouth the mandible moves together with the disc in the joint (aavity. It i8 like :1 i*nahjon betwcrn the bonv joint surfaces. Sp)?'itTS
1. Strengthening of the Joint’s Capsule Through the Articular Disc in the Case of Habitual Mandibular Luxation.-The excessive forward motion of the mandibular capitulum on the articular tubercle is a frequent occurrence; thus it might be appropriate to consider it as a subluxation rather than a complete luxation. Only in cases of irrevocable forward dislocations, where to accomplish a repositioning would Ijecome impo,ssible fo1 the patient, would the condition show a caomplete luxation. As a result, the ligaments of the joint would become dilated and relaxed, thus favoring the recurrence of this pathologic condition. It is clear, therefore, that the gravity of the case depends on the number of recurrent dislocations of the mandibular capitulum. In the further cOurse of events through the frequent incidence of luxations, the articular tubercle would be leveled off to a lesser degree of elevation in relation to its environment. This condition would invite further luxations of the mandibular joint as :i response to the slightest cause: thus the habitual luxation would come into existence. This situation in certain professions might involve difficulties of almost unbearable The case of an opera singer is cited who could not exercise her profession due character. to the frequent subluxations of her temporomandibular joint. The inspection of her oral condition brought to evidence a one-sided (unilateral) lesion of her mandibular articulation causing a deviation of the mandible toward the unaff’ected mandibular joint. Lindeconsists of the creation of a promann’s operation, which is not favored l)y the author, montorium on the articular tubercle with the purpose of stopping the mandibular capitulum in its excessive forward motion. The difficulty in con,serving the promontorium and the technical complications which would arise in achieving it makes this operation u poor
ABSTRACTS
OF
CTJRREKT
LITERATURE
1351
choice, and more so if we consider that this operative method might seriously hamper the regular course of wound healing. Rehn and Nieden tried to take advantage of the fasciae behind the ears and to use those tissues to reinforce the ligaments of the joint. However, this method did not become popular with most of the surgeons. Instead of that the author is in favor of using the articular disc in the form of a pedunculated transplant; the disc would be prepared in such a way as to maintain its organic unity with its environment. lt would be used to reinforce the joint’s capsule and at the same time to prevent the forward traction of the external pterygoid muscle. Theoretically, however, the same result might be obtained by cutting away the muscle tendon which is inserted on the articular disc. This operation is described as a separation of the disc in a posterior, lateral, and mesial aspect to the joint; its connection with the joint would remain in existence only in an anteromedial aspect. Thus having established a pedunculated disc the operator twines it around the anterior and lateral sides of the mandibular capitulum. Ultimately it would be sewed to the joint’s capsule and, due to its winding around the capitulum, it show.s a stretched condition. The picture in a carefully accomplished operation would result in the formation of a wide platform of tissue secured on the periosteum of the zygomatic process and on the neighboring cartilage of the ear. With this operation the author claims to have obtained complete recoveries without reeidivation. Other cases of .subluxation are brought up by the author in support of the method which he advises in a temporomandibular joint repair. In those eases pain and discomfort were the main reasons which brought about the treatment of the affected areas by the temporomandibular operation. It must be borne in mind that a definite deviation of the mandible toward the operated side is a frequent postoperative evidence. The operation is described as follows: Under local anesthesia an incision i’s performed on the anterior margin of the external ear, within the ear limits. This is followed by a free preparation of the zygomatic process and the temporomandibular joint’s capsule. This latter organ is incised and through the opening the flattened surface of the articular tubercle is visible. The relative ease with which the capitulum may glide over the eminentia is quite convincing. The connection of the disc with the rest of the joint is severed in a lateromedial and distal aspect. Thus the pedunculated disc will be twined around the capitulum anterolaterally; it would be sewed to the joint’s ligaments, to the periosteum Iof the zygomatic process, and to the cartilage of the tragus. The closure of the wound will be cared for by sutures applied by layers. Ivy ligatures are adapted with intermaxillary elastic bands for a few days in order to exclude an excessive mouth opening and to secure a rest position. In seven days, as a rule, the sutures are removed. A deviation of the mandible to the operated side may be clearly obaerved a month after the operation. The injection of sclerosing solutions into the joint’s capsule is strongly rejected by the author. 2. Anteposition of the Disc According to the Operation Described by Honjetzny in the Subluxation of the Temporomandibular Joint.-This operation has a disadvantage, though not serious, with respect to the patient. The movements of the mandible toward the operated side are limited. Unfortunately, however, should the need arise to operate on the mandibular joint on both sides (ambolateral), then the postoperative inconvenience of limited mandibular function would not be of indifference to the patient. That is the reason why the undertaking of this sort of operation should be considered only after wellsupported -indications. At Axhausen!s terminal cracking noise it may be observed, especially when the motions are somewhat limited, that the patient suffers severe pains at the opening of the mouth. Under these circumstances the author decisively advocates the operation. He lists a number of mechanical appliances which were adapted to the They were used for decades, only to be dismissed because cases according to their nature. of their disappointing results. So, among others, Schroeder’s glider splint and Andresen’s monoblock are mentioned. Also diathermy is used in combination with intermaxillary tractions through elastic bands, where the action of the pulling force would be anchored on the premolars.
1352
QUARTERLY
REVIEW
OF
IJTERATURIC
Konjetzny’s method of operation consists of separation of the articular disc lateromedioposteriorly and of fixin, m it in au anterior. luxation. 7’0 achieve this condition he sews the disc on the external pterygoid musc~le and on the orusseter. In many cases this suturing of the disc on the muscle might bc superfluous. It is interesting to note that the cracking noise and pain disappear as soon as the disc is not placed between capitulum and eminentia articularis. If a strengthening of the capsule is to be obtained, the author uses the same method which he would adopt iu the ‘surgical treatment of the habitual luxation. This operation, the author claims, does not impair the functional efficiency of the mandible and it is not of any cosmetic disadvantage to the patient. Agnin the author puts forth a few premonitory words of caution. As he points out, his own observations were scanty for they were extended over too short a postoperative period 10 enable anybody to formulate definite statements as to the success of the operations. Here are some points of interest in his surgical procedure: Konjetzny ‘s Method of Anteposition 01’ tbe Articdm Disc.--‘l’lle incision is performed on the margin of the tragus and it is drawn upward maintaining its course within the hair limits. It follows a bland preparation of the field until the post,erior end of the eygomatic process appears in the range of the operative field. The author does not believe in the so-called Bockenheimer-Axhauseri retroauricular incision. ‘l’ha next, act is the tying of the temporalis artery. A horizontal cut along the q-gomatic process followed by a crosswise incision of the joint’s capsule concludes the first pha.se of the operation. After a careful observation of the operative field, the mandibular c>apitulum is displaced from the joint cavity in a forward direction together with the attached articular disc. A further move would separate the disc from the joint’s capsule in a lateral and posterior aspect. With a gliding motion the tlisc should come lodged in a position which is anterior As a rule the cracking noise which accompanies the to the temporomandibular joint, opening of the mouth disappears at this phase of the operation. The author does not think that the tying of the disc to the anterior area is necessary. The joint’s capsule, the subcutaneous and the dermal tissues are cared f’or l,j- separate sutures. The postoperative treatment consists of putting on the elastic b:lnds. A careful inspection of the operated area many times brought to light a deviation of the mandible toward the operated side.
3. The Extirpation
of the Articular
Disc in Cases of Arthrosis
Complicated
With
Cracking Noise and Chondromatosis of the Mandibular Joint.-There are ca.ws which take the course of a serious onset and which lead eventually to an ankplosis. They are different in character from those described above and classified as subluxations. Tt is of intere,st to note that at the beginning of the ankylosed status of the mandible t,he cracking noise dominates the symptoms of injury of the joint (Axhausen’s intermediary cracking). As a rule there is no soreness on pressure of the outside area corresponding to the joint. Movassociated with a sensitive ing the mandible in backward direction, pain would appear, feeling. These symptoms signify a lesion of the mandibular joint, and in grave conditions like in the case of meniscal lesions of the knee joint, the treatment consists of the removal of the meniscus. Whether the disc act,ively participates in the lesion, or through its removal room has been created in the disea.sed joint and thus it is merely a passive conremains a matter of discussion. tributor to the abolition of s.ymptoms, As soon as the joint’s capsule is opened the fundamental difference in the functional quality of mandibular movement from the other lesion described before as luxation is clear to the keen observer. Thus the capitulum, instead of moving freely in forward motion over the However, this limited mandibular activity articular tubercle, is limited in its activities. would become free again following the excision of the articular disc. In the case of intermediary cracking noise alone without any further pathologic If there is a deep bite associated with pains of the symptom no operation is indicated. masticatory muscles, operation might be considered. Some observers assert that cases of this nature might be classified with arthritis deformans. The author could not convince himself on this statement neither by means of radiologic or by direct inspection of The operation is described as an initial incision on t,he margin of the operative field.
ABSTRACTS
OF
CURRENT
1353
LITERATURE
the tragus within the hair limits. There follows the tying of the artery and vein temPOralis and the free preparation of the field until the zygomatic process is within the operative area. A horizontal cut along the processus zygomaticus and opening of the joint’s capsule are the next move. As a rule in a regular-sized glenoid cavity a rather disproportionate, The disc seems to be thin and almost unmovable in a small capitulum is to be seen. medially displaced position. The author separated the disc in a lateral and posterior aspect. In the medioanterior view a small portion of the disc remained attached to the capitulum there where the external pterygoid tendon was located. In one particular history which the author cites in his article the report is given that the patient remembered the slow initial phase of the mandibular ankylosis which was preceded by mandibular cracking noise. In another case the author reports of a limited mandibular movement whereby it was deviated toward the side of the joint lesion. Thoma uses a spoon-shaped knife especially adapted for operations in the medial side of the joint, an area difficult of access. The author did not find any anatomical structural changes of the intra-articular area in these cases of mandibular lesions, nor has he encountered tearing or any other This finding differs from that often found in knee destructive alteration on the discs. joint lesions where the disc shows regressive change’s An indication to operate on the patient should be carefully weighed against conservative methods of treatment; and only when the latter procedures do not result in an improvement should the surgery be considered. A different view is expressed by the author in the case of ohondromato.sis of the mandibular joint, where intra-artieular, free, and small bodies of cartilage are spread over. Clinically the lesion is characterized by swelling of the area corre.sponding to the joint, by the tenderness to palpation, and by a clearly distinguished crepitation provoked by touch. There is no cracking noise to hear in the mandibular movement. While soreness is present during eating, it is less frequent in mandibular movements, as in speech. In the history of one case the soreness appeared first .sporadically (twice in a month), but after a certain lapse of time it became frequent and intensive. However, there were no mandibular functional limitations. In the local status of the lesion there was a eherrylike protuberance in the tragus area under the zygomatic process. The cutie was red in color and the subcutis of the same area showed the signs of an infiltration which on palpation gave a noise similar to crepitation. The operation is described as an incision performed on the cutis in a right angle, on the margin of the tragus and within hair limits. The joint is freed by reflection of the periosteal tissues from the bone surfaces which are On incision of the joint’s cap.sule, colorless, viscid in the range of the field of operation. liquid appears which contains white, transparent, rotund bodies. They exhibit a soft The articular disc is not changed in dimension and form. At its cartilage consistency. removal the posterior part which i,s inaccessible remains attached to the capitulum. One part of the joint’s capsule is removed and the remainder is sutured. The author distinguishes a terminal cracking noise in the case of mandibular subluxation and an intermediary cracking noise in the gravely affected mandibular lesions. However, it might occur that in the case of subluxation an intermediary cracking noise arises. In the case of arthritis deformans, the noise during mandibular movement resembles that which arises during rubbing of a rough tissue, and it is perceptible only by hands laid upon the joint area. A. G. N.
CLINICAL Prehistoric
Australian
and N. C. Manning.
AND LABORATORY
Aboriginal Australian
Skull With J. Dent.
RESEARCH
Carious Premolar 56:
Tooth.
Edmund
D. Gill
98, 1950.
During a National Museum collecting trip in the Western District of Victoria, part of an aboriginal skeleton was collected from Glenormiston North through the kind cooperation of Mr. A. G. T. Smith and the Terang Police. It proved interesting in that the upper jaw contained a highly various premolar tooth. Such teeth are not often found in aboriginal skulls, and some comment on the occurrence is offered.
OF
CURRENT
1349
LITERATURE
was readily controlled with epinephrine. The pathologic report was as follows: The specimen consisted of a flat pinkish gray mass, 1.1 by 0.8 by 0.3 cm. in size. It was covered on one surface by a finely granular epithelium; the under surface had a smooth, glistening appearance. Microscopically The bone present was 4 mm. in diameter and yellowish white. it was found to be essentially normal cancelloux bone showing myelofibro.sis. On November 21, another specimen for biopsy was taken in a similar manner from the same turbinate bone near the middle portion. This specimen grossly consisted of four irregularly shaped yellowish white piece.s of osseous material. On section the material was yellowish white and of uniformly hard consistency, with the exception of a small amount of soft osseou,s tissue seen at the base of one piece. Microscopically the mucous membrane showed a chronic inflammatory reaction, and the osseous tissue showed myelofibrotic changes compatible with early fibrous dysplasia.” T. J. C.
DISEASES Surgical
OF THE
MANDIBULAR
Operations on the Mandibular Joint With Regard Trauner. Deut’sche. zahniirzt. Ztschr. 5: 5, 1950.
JOINT to the
Articular
Disc.
Richard
Due to the rare occurrence of hematogenic infections of the mandible and considering rheumatoid arthritis as one of the potential sources of this sort of lesions, with the exception of trauma, diseases of the temporomandibular joint are rather infrequent, The more often observed bony inflammatory processes of the mandible are many times of local character and might be traced back to cau’ses which originate from teeth and ears. A strong expression of warning is put forward by the author with respect to operative interventions in the temporomandibular region, as most of the lesions of that area, may they be traumatic or otherwise, might be successfully treated without surgery. Thus Hofer of. Vienna has often demonstrated the unneceesary extirpation of the fractured mandibular capitulum, or its repositioning by surgery. However, if conditions do require a recourse to surgery, the condyloid process of the mandible may be removed without seriously impeding the functional fitness of the jaw through that procedure. This experimental proof becomes more convincing if its simple articulation and the lack of a static load on it are considered. There might be other circumstances under which the surgical approach of the mandibular joint cavity is indicated, e.g., in the case of actinomycosis, or in empyema. While an operation in these cases might be considered as a decisive intervention quoad vitam due to existing possibilities of a meningeal encroachment, it is not always clear whether the application of surgery i.s the response to sometimes not too valid indications, as it may occur in many instances that the signs and symptoms of grave lesions of the mandibular joint are completely lacking and thus worthless in adopting an indication for any treatment. The actinomycosis of the temporomandibular articulation often resembles a harmlesslooking fistula, and the empyema, because of the joint capsule’s tightly structured tissue, does not reveal any fluctuating prominence. The chondromatosis might be classified with mandibular joint lesions, although its occurrence, characterized by intra-articular bodies freely diepemed within the area covered by the joint’s capsule, is seldom encountered. The most frequent disturbance of the mandibular joint is the cracking noise, at the opening of the mouth, although even in this case surgery is rarely indicated. There are two forms of the noise phenomenon. In one type the excessive forward thrusting of the mandibular capitulum on the articular tubercle results in a loud cracking noise (Axhaueen’s terminal This type of cracking noise does not cause any particular subjective cracking noise). inconvenience to the patient. A method surgery, described by Konjetzny, according to which the discus articularis is di’splaced and fixed in an anterior aspect to the joint cavity, would eliminate the disturbance. This surgical intervention is simple and as a rule withIn the second type the cracking noise is accompanied by pain and out complications.
1350
Qt~ARTER1,1’
I
OF
f,ITEIZ.\‘I’t
:KI’
trismus. The noise originates already at. the! lleg:inning 01’ the inouth opening if ill0 I& mm a priori does not exclude such a movcrnen 1. However. :III operation on the joint might be indicated only if no improvement in 1111, condition we*-~ ollsorved IIF :L i~onsr~rvative method of treatment exclusively. The estirpat,ion of the ;crt irular disk would remove the trouble. A quite different view should l,e :rdopted in eases in whit-h lesions of the t.emporomandibular joint led to an existing ank~losis. This comlllim tion relatively often in childhood. Following operations in the ear, or as x result of scaarlet fever, anal :~lso as a posttyphoid lesion, often mandibular joint complications arise with an ankylosin of the temporoThe picture of ihe disease would 1~~ further aggrava.ted by a mandibular articulation. developing or existing microgenia due to the disarranged course of mandibular growth. The operation previously consisted of t.he smoothing of the glenoid cavity and in tapering of the condyloid process. However, the author, as well as other workers (Konig and Dufourmentel) who have availed themselrrs of this method of mandibular joint, surgery, has observed a regular recidivation of the preoperative lesion. Four cases among thirteen patients operated upon are reported by the author in which t,he lesion relapsed in a period of one year, In nine patients from ten operated upon, the lesion relapsed in ankylosis five years after the operation. It might be pointed out that at that time, in order to obtain a correction of these pathologic conditions, fa.sciae, musrles, Eden rubber were underlaid between the mandibular capitulum and the glenoid cavity. All these methods used and attempted by surgery have resulted in a failure. Today the picture of postoperative conditions is definitely better. Dufourmentel interlaces relatively great portions of cartilage taken from the ribs. The author uses cartilage from the ears which eovcrs the joint. cavity entirely. He emphasizes the advantages which derive from the use of the so-called activators designed and used according to the iunt,ructions given by Andresen. i\n applicator used postoperatively keeps the dental arches awa,v from each other. Topographically the articular disc lies horizontally between thr joint cavity of the temporal bone and the capitulum of the mandible. Through the disc the temporomandibular joint is divided into two parts. When the mandible moves in a forward direction the disc goes together with it by traction of the external pterygoid muscle. In the opening of the mouth the mandible moves together with the disc in the joint (aavity. It i8 like :1 i*nahjon betwcrn the bonv joint surfaces. Sp)?'itTS
1. Strengthening of the Joint’s Capsule Through the Articular Disc in the Case of Habitual Mandibular Luxation.-The excessive forward motion of the mandibular capitulum on the articular tubercle is a frequent occurrence; thus it might be appropriate to consider it as a subluxation rather than a complete luxation. Only in cases of irrevocable forward dislocations, where to accomplish a repositioning would Ijecome impo,ssible fo1 the patient, would the condition show a caomplete luxation. As a result, the ligaments of the joint would become dilated and relaxed, thus favoring the recurrence of this pathologic condition. It is clear, therefore, that the gravity of the case depends on the number of recurrent dislocations of the mandibular capitulum. In the further cOurse of events through the frequent incidence of luxations, the articular tubercle would be leveled off to a lesser degree of elevation in relation to its environment. This condition would invite further luxations of the mandibular joint as :i response to the slightest cause: thus the habitual luxation would come into existence. This situation in certain professions might involve difficulties of almost unbearable The case of an opera singer is cited who could not exercise her profession due character. to the frequent subluxations of her temporomandibular joint. The inspection of her oral condition brought to evidence a one-sided (unilateral) lesion of her mandibular articulation causing a deviation of the mandible toward the unaff’ected mandibular joint. Lindeconsists of the creation of a promann’s operation, which is not favored l)y the author, montorium on the articular tubercle with the purpose of stopping the mandibular capitulum in its excessive forward motion. The difficulty in con,serving the promontorium and the technical complications which would arise in achieving it makes this operation u poor
ABSTRACTS
OF
CTJRREKT
LITERATURE
1351
choice, and more so if we consider that this operative method might seriously hamper the regular course of wound healing. Rehn and Nieden tried to take advantage of the fasciae behind the ears and to use those tissues to reinforce the ligaments of the joint. However, this method did not become popular with most of the surgeons. Instead of that the author is in favor of using the articular disc in the form of a pedunculated transplant; the disc would be prepared in such a way as to maintain its organic unity with its environment. lt would be used to reinforce the joint’s capsule and at the same time to prevent the forward traction of the external pterygoid muscle. Theoretically, however, the same result might be obtained by cutting away the muscle tendon which is inserted on the articular disc. This operation is described as a separation of the disc in a posterior, lateral, and mesial aspect to the joint; its connection with the joint would remain in existence only in an anteromedial aspect. Thus having established a pedunculated disc the operator twines it around the anterior and lateral sides of the mandibular capitulum. Ultimately it would be sewed to the joint’s capsule and, due to its winding around the capitulum, it show.s a stretched condition. The picture in a carefully accomplished operation would result in the formation of a wide platform of tissue secured on the periosteum of the zygomatic process and on the neighboring cartilage of the ear. With this operation the author claims to have obtained complete recoveries without reeidivation. Other cases of .subluxation are brought up by the author in support of the method which he advises in a temporomandibular joint repair. In those eases pain and discomfort were the main reasons which brought about the treatment of the affected areas by the temporomandibular operation. It must be borne in mind that a definite deviation of the mandible toward the operated side is a frequent postoperative evidence. The operation is described as follows: Under local anesthesia an incision i’s performed on the anterior margin of the external ear, within the ear limits. This is followed by a free preparation of the zygomatic process and the temporomandibular joint’s capsule. This latter organ is incised and through the opening the flattened surface of the articular tubercle is visible. The relative ease with which the capitulum may glide over the eminentia is quite convincing. The connection of the disc with the rest of the joint is severed in a lateromedial and distal aspect. Thus the pedunculated disc will be twined around the capitulum anterolaterally; it would be sewed to the joint’s ligaments, to the periosteum Iof the zygomatic process, and to the cartilage of the tragus. The closure of the wound will be cared for by sutures applied by layers. Ivy ligatures are adapted with intermaxillary elastic bands for a few days in order to exclude an excessive mouth opening and to secure a rest position. In seven days, as a rule, the sutures are removed. A deviation of the mandible to the operated side may be clearly obaerved a month after the operation. The injection of sclerosing solutions into the joint’s capsule is strongly rejected by the author. 2. Anteposition of the Disc According to the Operation Described by Honjetzny in the Subluxation of the Temporomandibular Joint.-This operation has a disadvantage, though not serious, with respect to the patient. The movements of the mandible toward the operated side are limited. Unfortunately, however, should the need arise to operate on the mandibular joint on both sides (ambolateral), then the postoperative inconvenience of limited mandibular function would not be of indifference to the patient. That is the reason why the undertaking of this sort of operation should be considered only after wellsupported -indications. At Axhausen!s terminal cracking noise it may be observed, especially when the motions are somewhat limited, that the patient suffers severe pains at the opening of the mouth. Under these circumstances the author decisively advocates the operation. He lists a number of mechanical appliances which were adapted to the They were used for decades, only to be dismissed because cases according to their nature. of their disappointing results. So, among others, Schroeder’s glider splint and Andresen’s monoblock are mentioned. Also diathermy is used in combination with intermaxillary tractions through elastic bands, where the action of the pulling force would be anchored on the premolars.
1352
QUARTERLY
REVIEW
OF
IJTERATURIC
Konjetzny’s method of operation consists of separation of the articular disc lateromedioposteriorly and of fixin, m it in au anterior. luxation. 7’0 achieve this condition he sews the disc on the external pterygoid musc~le and on the orusseter. In many cases this suturing of the disc on the muscle might bc superfluous. It is interesting to note that the cracking noise and pain disappear as soon as the disc is not placed between capitulum and eminentia articularis. If a strengthening of the capsule is to be obtained, the author uses the same method which he would adopt iu the ‘surgical treatment of the habitual luxation. This operation, the author claims, does not impair the functional efficiency of the mandible and it is not of any cosmetic disadvantage to the patient. Agnin the author puts forth a few premonitory words of caution. As he points out, his own observations were scanty for they were extended over too short a postoperative period 10 enable anybody to formulate definite statements as to the success of the operations. Here are some points of interest in his surgical procedure: Konjetzny ‘s Method of Anteposition 01’ tbe Articdm Disc.--‘l’lle incision is performed on the margin of the tragus and it is drawn upward maintaining its course within the hair limits. It follows a bland preparation of the field until the post,erior end of the eygomatic process appears in the range of the operative field. The author does not believe in the so-called Bockenheimer-Axhauseri retroauricular incision. ‘l’ha next, act is the tying of the temporalis artery. A horizontal cut along the q-gomatic process followed by a crosswise incision of the joint’s capsule concludes the first pha.se of the operation. After a careful observation of the operative field, the mandibular c>apitulum is displaced from the joint cavity in a forward direction together with the attached articular disc. A further move would separate the disc from the joint’s capsule in a lateral and posterior aspect. With a gliding motion the tlisc should come lodged in a position which is anterior As a rule the cracking noise which accompanies the to the temporomandibular joint, opening of the mouth disappears at this phase of the operation. The author does not think that the tying of the disc to the anterior area is necessary. The joint’s capsule, the subcutaneous and the dermal tissues are cared f’or l,j- separate sutures. The postoperative treatment consists of putting on the elastic b:lnds. A careful inspection of the operated area many times brought to light a deviation of the mandible toward the operated side.
3. The Extirpation
of the Articular
Disc in Cases of Arthrosis
Complicated
With
Cracking Noise and Chondromatosis of the Mandibular Joint.-There are ca.ws which take the course of a serious onset and which lead eventually to an ankplosis. They are different in character from those described above and classified as subluxations. Tt is of intere,st to note that at the beginning of the ankylosed status of the mandible t,he cracking noise dominates the symptoms of injury of the joint (Axhausen’s intermediary cracking). As a rule there is no soreness on pressure of the outside area corresponding to the joint. Movassociated with a sensitive ing the mandible in backward direction, pain would appear, feeling. These symptoms signify a lesion of the mandibular joint, and in grave conditions like in the case of meniscal lesions of the knee joint, the treatment consists of the removal of the meniscus. Whether the disc act,ively participates in the lesion, or through its removal room has been created in the disea.sed joint and thus it is merely a passive conremains a matter of discussion. tributor to the abolition of s.ymptoms, As soon as the joint’s capsule is opened the fundamental difference in the functional quality of mandibular movement from the other lesion described before as luxation is clear to the keen observer. Thus the capitulum, instead of moving freely in forward motion over the However, this limited mandibular activity articular tubercle, is limited in its activities. would become free again following the excision of the articular disc. In the case of intermediary cracking noise alone without any further pathologic If there is a deep bite associated with pains of the symptom no operation is indicated. masticatory muscles, operation might be considered. Some observers assert that cases of this nature might be classified with arthritis deformans. The author could not convince himself on this statement neither by means of radiologic or by direct inspection of The operation is described as an initial incision on t,he margin of the operative field.
ABSTRACTS
OF
CURRENT
1353
LITERATURE
the tragus within the hair limits. There follows the tying of the artery and vein temPOralis and the free preparation of the field until the zygomatic process is within the operative area. A horizontal cut along the processus zygomaticus and opening of the joint’s capsule are the next move. As a rule in a regular-sized glenoid cavity a rather disproportionate, The disc seems to be thin and almost unmovable in a small capitulum is to be seen. medially displaced position. The author separated the disc in a lateral and posterior aspect. In the medioanterior view a small portion of the disc remained attached to the capitulum there where the external pterygoid tendon was located. In one particular history which the author cites in his article the report is given that the patient remembered the slow initial phase of the mandibular ankylosis which was preceded by mandibular cracking noise. In another case the author reports of a limited mandibular movement whereby it was deviated toward the side of the joint lesion. Thoma uses a spoon-shaped knife especially adapted for operations in the medial side of the joint, an area difficult of access. The author did not find any anatomical structural changes of the intra-articular area in these cases of mandibular lesions, nor has he encountered tearing or any other This finding differs from that often found in knee destructive alteration on the discs. joint lesions where the disc shows regressive change’s An indication to operate on the patient should be carefully weighed against conservative methods of treatment; and only when the latter procedures do not result in an improvement should the surgery be considered. A different view is expressed by the author in the case of ohondromato.sis of the mandibular joint, where intra-artieular, free, and small bodies of cartilage are spread over. Clinically the lesion is characterized by swelling of the area corre.sponding to the joint, by the tenderness to palpation, and by a clearly distinguished crepitation provoked by touch. There is no cracking noise to hear in the mandibular movement. While soreness is present during eating, it is less frequent in mandibular movements, as in speech. In the history of one case the soreness appeared first .sporadically (twice in a month), but after a certain lapse of time it became frequent and intensive. However, there were no mandibular functional limitations. In the local status of the lesion there was a eherrylike protuberance in the tragus area under the zygomatic process. The cutie was red in color and the subcutis of the same area showed the signs of an infiltration which on palpation gave a noise similar to crepitation. The operation is described as an incision performed on the cutis in a right angle, on the margin of the tragus and within hair limits. The joint is freed by reflection of the periosteal tissues from the bone surfaces which are On incision of the joint’s cap.sule, colorless, viscid in the range of the field of operation. liquid appears which contains white, transparent, rotund bodies. They exhibit a soft The articular disc is not changed in dimension and form. At its cartilage consistency. removal the posterior part which i,s inaccessible remains attached to the capitulum. One part of the joint’s capsule is removed and the remainder is sutured. The author distinguishes a terminal cracking noise in the case of mandibular subluxation and an intermediary cracking noise in the gravely affected mandibular lesions. However, it might occur that in the case of subluxation an intermediary cracking noise arises. In the case of arthritis deformans, the noise during mandibular movement resembles that which arises during rubbing of a rough tissue, and it is perceptible only by hands laid upon the joint area. A. G. N.
CLINICAL Prehistoric
Australian
and N. C. Manning.
AND LABORATORY
Aboriginal Australian
Skull With J. Dent.
RESEARCH
Carious Premolar 56:
Tooth.
Edmund
D. Gill
98, 1950.
During a National Museum collecting trip in the Western District of Victoria, part of an aboriginal skeleton was collected from Glenormiston North through the kind cooperation of Mr. A. G. T. Smith and the Terang Police. It proved interesting in that the upper jaw contained a highly various premolar tooth. Such teeth are not often found in aboriginal skulls, and some comment on the occurrence is offered.