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Use of a new instrument for lateral release in arthroscopic surgery of the temporomandibular joint: a preliminary study
British Journal of Oral and Maxillofacial Surgery (2004) 42, 166—169
SHORT COMMUNICATION
Use of a new instrument for lateral release in arthroscopic surgery of the temporomandibular joint: a preliminary study Tomoaki Shibuya a,*, Koji Kino b , Hiroyuki Yoshitake c , Hakubun Yonezu d , Teruo Amagasa e , Tetsu Takahashi f a
Second Department of Oral and Maxillofacial Surgery, Kyushu Dental College, 2-6-1 Manazuru, Kokurakitaku, Kitakyushu City, Fukuoka 803-8580, Japan b Temporomandibular Joint Clinic, Faculty of Dentistry, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan c Division of Maxillofacial and Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan d Second Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 1-2-2 Masuna, Mihamaku, Chiba City 261-8502, Japan e Division of Maxillofacial and Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan f Second Department of Oral and Maxillofacial Surgery, Kyushu Dental College, 2-6-1 Manazuru, Kokurakitaku, Kitakyushu City, Fukuoka 803-8580, Japan Accepted 30 October 2003
KEYWORDS Arthroscopy; Temporomandibular joint; Temporomandibular disorders
Summary We developed a new instrument, which we call a lateral releaser, to improve the safety of either a blind lateral release or lateral stretching within the TMJ We used it during arthroscopic surgery in patients with chronic painful hypomobility of the temporomandibular joint (TMJ). We operated on 24 TMJs in 17 patients (15 women and 2 men). At operation, the mean increase in the interincisal distance was 22 mm (range 10—32). No instruments were broken. No serious surgical complications were reported during or after operation. Many of the patients currently have an interincisal distance exceeding 38 mm. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Arthroscopy of the temporomandibular joint (TMJ) was first reported by Ohnishi.1 Moses and *Corresponding author. Tel.: +81-93-582-1131; fax: +81-93-592-3056. E-mail address: [email protected] (T. Shibuya).
Poker pointed out the importance of the capsular stretch procedure or capsular release for joint mobility.2 We have, therefore, developed a new instrument, which we call a lateral releaser, to improve the safety of either a blind lateral release or lateral stretching within the TMJ.3
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00237-7
Use of a new instrument for lateral release in arthroscopic surgery
167
Table 1 Preoperative details of the patients. Age (year)
Diagnosis
Affected side
Operated side
Preoperative Non-surgical mouth treatment period (weeks) opening (mm)
Preoperative pain
1 2 3
32 19 24
Bilateral Right Left
Bilateral Right Left
24 64 124
22 27 26
Arthralgia, muscle pain Arthralgia Arthralgia
4 5 6 6 7 7 8 9
27 21 29 30 27 28 50 65
Left Left Bilateral Bilateral Bilateral Bilateral Bilateral Left
Left Left Left Right Left Left Bilateral Left
52 16 44 96a 67 129b 12 24
25 20 30 30 35 35 24 22
Arthralgia, Arthralgia, Arthralgia, Arthralgia Arthralgia Arthralgia Arthralgia, Arthralgia
10 11 12
45 51 53
Bilateral Left Right
Bilateral Left Right
180 52 24
23 34 37
Arthralgia Arthralgia, muscle pain Arthralgia, muscle pain
13 14 15 16 17
41 29 30 23 28
Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion Adhesion Adhesion
Right Bilateral Bilateral Right Right
Right Bilateral Bilateral Right Right
143 18 12 24 28
24 23 20 40 20
Arthralgia, muscle pain
Case no.
muscle pain muscle pain muscle pain
muscle pain
Arthralgia Arthralgia Arthralgia
All patients had anterior disc displacement without reduction, and cases 6 and 16 were two only men. a Treatment period before second operation (on right). b Treatment period before second operation (on left).
Patients and methods We used the lateral releaser during arthroscopic operations in 17 patients with chronic painful hypo-
Figure 1
mobility of the TMJ. Magnetic resonance imaging showed anterior disc displacement without reduction. We operated on 24 TMJs in 17 patients (15 women and 2 men) (Table 1).
The releasing manoeuvre.
168
T. Shibuya et al.
The arthroscope is inserted under general anesthesia. After the joint space has been inspected and adhesions lysed, the arthroscopic cannula is removed and the tip of the lateral releaser inserted through the incision into the joint cavity. When a sensation of resistance is felt, the tip is repeatedly stretched outwards and upwards along the surface of the tubercle. After a sufficient range of movement has been achieved, the joint cavity is again arthroscoped. Fig. 1 shows the manoeuvre used for lateral release and stretching. The criteria for success were that arthralgia disappeared and mouth opening was more than 38 mm.4
Results The patients ranged in age from 19 to 65 years (mean 34), and the female:male ratio was 5:1. Both joints were treated in 6 patients and only one in 11 patients. The mean preoperative interincisal mouth opening distance was 27 mm (range 20—40) (Table 1). At the end of operation, the mean increase in the distance was 22 mm (range 10—32). No instruments were broken. No serious complications were reported during or after the operation. Table 2 Findings during operation and postoperative course. Case no.
Mouth opening Mouth opening Pain at at the follow- follow-up at operation up (mm) (mm)
1 2 3 4 5 6 6 7 7 8 9 10 11 12 13 14 15 16 17
35 49 56 53 52 50 53 56 50 50 50 37 55 55 49 35 50 50 50
38 52 31 40 38
Arthralgia Muscle pain Muscle pain
39 37 39 39 30 40 43 49 40 30 40 40
Arthralgia
Muscle pain Muscle pain Arthralgia Arthralgia
All patients had signs of lateral adhesion and construction of the joint cavity on arthroscopy; case 3 also had a perforated disc.
At present, many of the patients have an interincisal distance exceeding 38 mm (Table 2). The success rate was 13/17 joints.
Discussion Persistent restricted movement of the TMJ probably makes the lateral wall less pliable. Some researchers have stressed the importance of lateral stretching and release for improving condylar mobility.2 Two anatomical features can explain this improvement. There are firstly, that the articular disc is attached mainly to the lateral and medial pole of the condyle and has no strong fibrous attachment to the temporal bone,5 and secondly, that the condyle is suspended from the temporal bone by the lateral ligament, but the fibers of the disc do not combine with those of the lateral ligament.6 The condyle and disc can swing, therefore, back and forth as one unit. If the flexibility of the lateral wall involving the lateral ligament recovers, it follows that the condyle and disc will be able to move more easily. If there are multiple adhesions or extensive fibrous change in the joint cavity, however, merely dividing the adhesions may not have a lasting effect, even when the operation produces temporal mobility of the condyle. Some surgeons have used a double puncture technique to achieve lateral release. Two cannulas are inserted into the joint space, one for the arthroscope and one for the surgical instrument.7 It is difficult, however to insert a thick instrument into the narrow joint space to do a lateral release together with an arthroscope. Furthermore, instruments may break because of the large force exerted for the stretching, because the arthroscopic trocar and sheath for TMJ are not as strong as those for other joints. The single-puncture technique that we use is easier than the double-puncture technique. Although the operation is blind, the shape of the instrument allows it to be inserted into the joint cavity easily without damaging the lateral wall. It is also strong enough to withstand the stretching force.
References 1. Ohnishi M. Arthroscopy of the temporomandibular joint. J Stomatological Soc Jpn 1975;42:207—13. 2. Moses JJ, Poker ID. TMJ arthroscopic surgery an analysis of 237 patients. J Oral Maxillofac Surg 1989;47:790—4. 3. Kino K, Shibuya T, Yoshitake H, Amagasa T, Yonezu H, Sugisaki M. Instrument for lateral release in temporomandibular joint hypomobility. Oral Surg Oral Med Oral Pathol 2000;89:398— 401.
Use of a new instrument for lateral release in arthroscopic surgery 4. Murakami K, Segami N, Okamoto M, Yamamura I, Takahashi K, Tsuboi Y. Outcome of the arthroscopic surgery for internal derangement of the temporomandibular joint long-term results covering 10 years. J Craniomaxillofac Surg 2000;28:264— 71. 5. Kino K, Ohmura Y, Amagasa T. Reconsideration of the bilaminar zone in the retrodiskal area of the temporomandibu-
169
lar joint. Oral Surg Oral Med Oral Pathol 1993;75:410— 21. 6. Ohmura Y. Histological observation on the structure of the lateral wall of the human temporomandibular joint. J Stomatological Soc Jpn 1984;51:465—92. 7. Joseph P, McCain DMD. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg 1988;46:648—55.
SHORT COMMUNICATION
Use of a new instrument for lateral release in arthroscopic surgery of the temporomandibular joint: a preliminary study Tomoaki Shibuya a,*, Koji Kino b , Hiroyuki Yoshitake c , Hakubun Yonezu d , Teruo Amagasa e , Tetsu Takahashi f a
Second Department of Oral and Maxillofacial Surgery, Kyushu Dental College, 2-6-1 Manazuru, Kokurakitaku, Kitakyushu City, Fukuoka 803-8580, Japan b Temporomandibular Joint Clinic, Faculty of Dentistry, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan c Division of Maxillofacial and Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan d Second Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 1-2-2 Masuna, Mihamaku, Chiba City 261-8502, Japan e Division of Maxillofacial and Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8549, Japan f Second Department of Oral and Maxillofacial Surgery, Kyushu Dental College, 2-6-1 Manazuru, Kokurakitaku, Kitakyushu City, Fukuoka 803-8580, Japan Accepted 30 October 2003
KEYWORDS Arthroscopy; Temporomandibular joint; Temporomandibular disorders
Summary We developed a new instrument, which we call a lateral releaser, to improve the safety of either a blind lateral release or lateral stretching within the TMJ We used it during arthroscopic surgery in patients with chronic painful hypomobility of the temporomandibular joint (TMJ). We operated on 24 TMJs in 17 patients (15 women and 2 men). At operation, the mean increase in the interincisal distance was 22 mm (range 10—32). No instruments were broken. No serious surgical complications were reported during or after operation. Many of the patients currently have an interincisal distance exceeding 38 mm. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Arthroscopy of the temporomandibular joint (TMJ) was first reported by Ohnishi.1 Moses and *Corresponding author. Tel.: +81-93-582-1131; fax: +81-93-592-3056. E-mail address: [email protected] (T. Shibuya).
Poker pointed out the importance of the capsular stretch procedure or capsular release for joint mobility.2 We have, therefore, developed a new instrument, which we call a lateral releaser, to improve the safety of either a blind lateral release or lateral stretching within the TMJ.3
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00237-7
Use of a new instrument for lateral release in arthroscopic surgery
167
Table 1 Preoperative details of the patients. Age (year)
Diagnosis
Affected side
Operated side
Preoperative Non-surgical mouth treatment period (weeks) opening (mm)
Preoperative pain
1 2 3
32 19 24
Bilateral Right Left
Bilateral Right Left
24 64 124
22 27 26
Arthralgia, muscle pain Arthralgia Arthralgia
4 5 6 6 7 7 8 9
27 21 29 30 27 28 50 65
Left Left Bilateral Bilateral Bilateral Bilateral Bilateral Left
Left Left Left Right Left Left Bilateral Left
52 16 44 96a 67 129b 12 24
25 20 30 30 35 35 24 22
Arthralgia, Arthralgia, Arthralgia, Arthralgia Arthralgia Arthralgia Arthralgia, Arthralgia
10 11 12
45 51 53
Bilateral Left Right
Bilateral Left Right
180 52 24
23 34 37
Arthralgia Arthralgia, muscle pain Arthralgia, muscle pain
13 14 15 16 17
41 29 30 23 28
Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion, disc perforation Adhesion Adhesion Adhesion Adhesion Adhesion
Right Bilateral Bilateral Right Right
Right Bilateral Bilateral Right Right
143 18 12 24 28
24 23 20 40 20
Arthralgia, muscle pain
Case no.
muscle pain muscle pain muscle pain
muscle pain
Arthralgia Arthralgia Arthralgia
All patients had anterior disc displacement without reduction, and cases 6 and 16 were two only men. a Treatment period before second operation (on right). b Treatment period before second operation (on left).
Patients and methods We used the lateral releaser during arthroscopic operations in 17 patients with chronic painful hypo-
Figure 1
mobility of the TMJ. Magnetic resonance imaging showed anterior disc displacement without reduction. We operated on 24 TMJs in 17 patients (15 women and 2 men) (Table 1).
The releasing manoeuvre.
168
T. Shibuya et al.
The arthroscope is inserted under general anesthesia. After the joint space has been inspected and adhesions lysed, the arthroscopic cannula is removed and the tip of the lateral releaser inserted through the incision into the joint cavity. When a sensation of resistance is felt, the tip is repeatedly stretched outwards and upwards along the surface of the tubercle. After a sufficient range of movement has been achieved, the joint cavity is again arthroscoped. Fig. 1 shows the manoeuvre used for lateral release and stretching. The criteria for success were that arthralgia disappeared and mouth opening was more than 38 mm.4
Results The patients ranged in age from 19 to 65 years (mean 34), and the female:male ratio was 5:1. Both joints were treated in 6 patients and only one in 11 patients. The mean preoperative interincisal mouth opening distance was 27 mm (range 20—40) (Table 1). At the end of operation, the mean increase in the distance was 22 mm (range 10—32). No instruments were broken. No serious complications were reported during or after the operation. Table 2 Findings during operation and postoperative course. Case no.
Mouth opening Mouth opening Pain at at the follow- follow-up at operation up (mm) (mm)
1 2 3 4 5 6 6 7 7 8 9 10 11 12 13 14 15 16 17
35 49 56 53 52 50 53 56 50 50 50 37 55 55 49 35 50 50 50
38 52 31 40 38
Arthralgia Muscle pain Muscle pain
39 37 39 39 30 40 43 49 40 30 40 40
Arthralgia
Muscle pain Muscle pain Arthralgia Arthralgia
All patients had signs of lateral adhesion and construction of the joint cavity on arthroscopy; case 3 also had a perforated disc.
At present, many of the patients have an interincisal distance exceeding 38 mm (Table 2). The success rate was 13/17 joints.
Discussion Persistent restricted movement of the TMJ probably makes the lateral wall less pliable. Some researchers have stressed the importance of lateral stretching and release for improving condylar mobility.2 Two anatomical features can explain this improvement. There are firstly, that the articular disc is attached mainly to the lateral and medial pole of the condyle and has no strong fibrous attachment to the temporal bone,5 and secondly, that the condyle is suspended from the temporal bone by the lateral ligament, but the fibers of the disc do not combine with those of the lateral ligament.6 The condyle and disc can swing, therefore, back and forth as one unit. If the flexibility of the lateral wall involving the lateral ligament recovers, it follows that the condyle and disc will be able to move more easily. If there are multiple adhesions or extensive fibrous change in the joint cavity, however, merely dividing the adhesions may not have a lasting effect, even when the operation produces temporal mobility of the condyle. Some surgeons have used a double puncture technique to achieve lateral release. Two cannulas are inserted into the joint space, one for the arthroscope and one for the surgical instrument.7 It is difficult, however to insert a thick instrument into the narrow joint space to do a lateral release together with an arthroscope. Furthermore, instruments may break because of the large force exerted for the stretching, because the arthroscopic trocar and sheath for TMJ are not as strong as those for other joints. The single-puncture technique that we use is easier than the double-puncture technique. Although the operation is blind, the shape of the instrument allows it to be inserted into the joint cavity easily without damaging the lateral wall. It is also strong enough to withstand the stretching force.
References 1. Ohnishi M. Arthroscopy of the temporomandibular joint. J Stomatological Soc Jpn 1975;42:207—13. 2. Moses JJ, Poker ID. TMJ arthroscopic surgery an analysis of 237 patients. J Oral Maxillofac Surg 1989;47:790—4. 3. Kino K, Shibuya T, Yoshitake H, Amagasa T, Yonezu H, Sugisaki M. Instrument for lateral release in temporomandibular joint hypomobility. Oral Surg Oral Med Oral Pathol 2000;89:398— 401.
Use of a new instrument for lateral release in arthroscopic surgery 4. Murakami K, Segami N, Okamoto M, Yamamura I, Takahashi K, Tsuboi Y. Outcome of the arthroscopic surgery for internal derangement of the temporomandibular joint long-term results covering 10 years. J Craniomaxillofac Surg 2000;28:264— 71. 5. Kino K, Ohmura Y, Amagasa T. Reconsideration of the bilaminar zone in the retrodiskal area of the temporomandibu-
169
lar joint. Oral Surg Oral Med Oral Pathol 1993;75:410— 21. 6. Ohmura Y. Histological observation on the structure of the lateral wall of the human temporomandibular joint. J Stomatological Soc Jpn 1984;51:465—92. 7. Joseph P, McCain DMD. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg 1988;46:648—55.