- Email: [email protected]
Use of Coblation in Arthroscopic Surgery of the Temporomandibular Joint
J Oral Maxillofac Surg 68:2085-2091, 2010
Use of Coblation in Arthroscopic Surgery of the Temporomandibular Joint Min Jie Chen, DDS, PhD, MD,* Chi Yang, DDS, PhD, MD,† Shan Yong Zhang, DDS, MS,‡ and Xie Yi Cai, DDS, PhD, MD§ Purpose: To evaluate the effectiveness of Coblation in temporomandibular joint (TMJ) arthroscopic
surgeries and to preliminarily evaluate the clinical effects. Materials and Methods: Arthroscopic Coblation, combined with disc suturing, was performed in 419 TMJs from July 2001 to March 2007 by use of the ArthroCare System 2000 radiofrequency machine (ArthroCare, Sunnyvale, CA). All patients had stage II to V internal derangement, according to the classification of Wilkes. Besides disc suturing, the technique of Coblation was used in procedures of adhesion ablation, anterior release, chondroplasty, and discoplasty. All patients were followed up for 3 months and evaluated based on immediate arthroscopic findings, by clinical examination, and by magnetic resonance imaging examination. Results: During the TMJ arthroscopic surgeries, the adhesion, unhealthy disc, and cartilage were ablated completely. The surface of the cartilage and disc were smooth without cautery damage and hemorrhage. During the clinical follow-up period, 76.37% of TMJs (320/419) had excellent results and 16.47% (69/419) had good results. The success rate was 92.84%. Masseter muscle atrophy occurred in 4 patients, and 30 TMJs required second arthroscopic surgeries or open surgeries. Conclusions: The technique of Coblation has proved to be an effective and minimally invasive option for the treatment of TMJ internal derangement, with advantages such as offering a high degree of precision and control, causing little or no thermal damage to surrounding tissue, leaving smooth anatomic surfaces, and achieving hemostasis of smaller blood vessels. © 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:2085-2091, 2010 Coblation, or “cold ablation,” is a process by which radiofrequency electrical charges are passed through saline solution, producing a plasma (or charged beam of ions) that can be focused very precisely. This ion beam has sufficient energy to break the
Received from the Department of Oral and Maxillofacial Surgery, School of Stomatology, Shanghai Ninth People’s Hospital, and School of Medicine, Shanghai Jiao Tong University, Shanghai, China. *Associate Professor. †Professor. ‡Attending Doctor. §Associate Professor. This study is supported by a grant from the Shanghai Leading Academic Discipline Fund (Y0203), the Science and Technology Commission of Shanghai (080Z2271100). Address correspondence and reprint requests to Dr Yang: Department of Oral and Maxillofacial Surgery, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, 639 Zhizaoju Rd, Shanghai, 200011, People’s Republic of China; e-mail: [email protected] © 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6809-0009$36.00/0 doi:10.1016/j.joms.2009.04.130
molecular bonds within cells, leading to cellular rupture and the dissolution of targeted tissues. Because radiofrequency current does not pass directly through the tissues, Coblation itself is a lowtemperature technique (in the range of 40°C to 70°C).1-3 As a result, Coblation devices break apart and debride targeted tissues at low temperatures, with minimal effects on surrounding tissues. Lasers, electrosurgical units, and other conventional radiofrequency surgical devices use less precise thermal energy to cut or coagulate tissue at temperatures in excess of 400°C.4-7 The heat can penetrate deeply, producing inadvertent damage to surrounding tissues. This ability to produce precise volumetric tissue removal has made Coblation devices very useful for a number of nasopharyngeal airway procedures, urologic and gynecologic procedures, plastic surgery, herniated spinal disc decompression, and arthroscopic procedures in both large and small joints.1-3,8-10 The purpose of this study was to evaluate the use of Coblation in arthroscopic surgery of the temporomandibular joint (TMJ). To our knowledge, this is the first time a follow-up of TMJ Coblation has been reported.
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COBLATION IN TEMPOROMANDIBULAR JOINT SURGERY
Table 1. FOUR MAIN LESIONS IN DIFFERENT STAGES OF ID
Stage II (No. of TMJs)
Stage III (No. of TMJs)
Stage IV (No. of TMJs)
Stage V (No. of TMJs)
Total (No. of TMJs)
16 0 0 0
283 94 0 0
60 31 0 39
60 44 60 27
419 169 60 66
Anterior displacement Adhesion Perforation Chondral damage
Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
Materials and Methods PATIENTS
We studied a consecutive series of 352 patients (419 TMJs) who had been referred to our department because of closed-lock or TMJ pain from July 2001 to March 2007. The patients consisted of 50 males and 302 females with a mean age of 33.3 years (range, 15-72 years). All showed no improvement after conservative therapy. The mean duration of symptoms was 24.1 months (range, 2 months to 20 years). According to clinical examination and magnetic resonance (MR) findings, all patients included in the study were diagnosed with internal derangement (ID). Many had accompanying intra-articular lesions that we believed would benefit from arthroscopic surgery. On the basis of arthroscopic findings, anterior displacement of disc was the main lesion that occurred in each patient, and the other 3 accompanying lesions—adhesion, perforation, and chondral damage— were found in 227 TMJs. Different lesions in different ID stages are shown in Table 1.
the Coblation wand was introduced through the cannula in the anterior recess (Fig 1). Occasionally, they were reversed. The joint was lavaged with saline solution during the whole procedure. After the diagnosis was established, arthroscopic surgery was performed. The main techniques are as follows:
EQUIPMENT
The Coblation device uses bipolar radiofrequency energy (ArthroCare System 2000; ArthroCare, Sunnyvale, CA) whose power is classified into 1 to 9 grades. The probe is at a 0° angle and measures 1.5 mm in diameter. The arthroscopic system includes a 2.3-mm, 0° angle– view Stryker optical system, a Stryker light source (Stryker Corporation, Kalamazoo, MI), and a Sony video recorder and color monitor (Sony Corporation, Minato, Tokyo, Japan). SURGICAL TECHNIQUE
All arthroscopic procedures were performed with the patient under local anesthesia by the same arthroscopist. The triple-channel arthroscopic technique of McCain11 was used. The lateral anterior channels were used for adhesion ablation, anterior release, chondroplasty, and discoplasty. The lateral ear canal channel was used for suturing. The arthroscope was usually introduced through the cannula in the posterior recess of the superior joint space, and
FIGURE 1. The arthroscope and Coblation probe were inserted into 2 cannulas, with the Coblation probe in the anterior recess and the arthroscope in the posterior recess. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
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CHEN ET AL
FIGURE 2. Coblation for adhesion ablation. A, Adhesion in anterior recess of superior joint space. B, Procedure of adhesion release with scissors. C, Procedure of adhesion ablation with Coblation probe. D, Smooth surface of cartilage and disc after operation. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
1. In cases having fibrous adhesions, they are first removed by use of hand instruments (scissors and forceps) or by Coblation (Figs 2A-C). 2. After the condyle is returned to the fossa, the arthroscope is advanced into the anterior recess. Additional local anesthetic is injected through the anterior cannula to avoid deep pain (Fig 3A). 3. The Coblation probe is used to release the anterior attachment of the disc and a portion of the lateral pterygoid muscle. This allows the disc to reduce easily and effectively. The incision line is located approximately 2 to 3 mm anterior to the anterior band of the disc, along the entire medial-to-lateral breadth of the anterior recess (Figs 3B,C). The depth is between 2 and 5 mm. The synovium is incised, and bleeding is coagulated by the Coblation tip until muscle fibers can be seen clearly. A blunt probe is introduced through the anterior cannula to release the muscle further and to reposition the disc (Figs 3D,E). 4. The posterior margin of the disc is sutured, and the position and function of the disc are confirmed. The details of our suturing technique will be described in another article. 5. If there is damaged cartilage, the Coblation probe is used to smooth the surfaces (Fig 4A).
6. A small perforation of the retrodiscal tissue is closed with suturing. A large perforation of the central part of the disc is treated with the Coblation probe. The edges of the disc are trimmed, and degenerative fibrocartilage is removed from the surface of the eminence. The procedures used for different stages of ID are listed in Table 2. EVALUATION
MR imaging examinations 1 week after surgery were performed to evaluate the position of the disc. Results were deemed excellent if all MR sagittal figures of the lateral one third, central one third, and medial one third of the condyle show that the posterior margin of the disc occupies the 11- to 1-o’clock location in relation to the condylar head in the closed-mouth position; good if 2 parts of MR sagittal figures (lateral one third, central one third, and medial one third) show that the posterior margin of the disc occupies the 11- to 1-o’clock location in relation to the condylar head; or poor if only 1 part or none of the MR sagittal figures (lateral one third, central one third, and medial one third) show that the posterior margin of the disc occupies the 11- to 1-o’clock loca-
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COBLATION IN TEMPOROMANDIBULAR JOINT SURGERY
FIGURE 3. Coblation for anterior release. A, Local anesthesia to prevent deep pain. B, C, Cutting line located approximately 2 to 3 mm anterior to anterior band of disc, along entire medial-to-lateral breadth of anterior recess, and procedure of releasing anterior attachment of disc and partial lateral pterygoid muscle with Coblation. D, E, Procedure of releasing attachment further and repositioning disc with blunt probe. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
tion in relation to the condylar head. If the result is poor, a second arthroscopic surgery or open surgery can be performed to correct the position of the disc. Clinical criteria were based on data from Murakami et al12 and the American Association of Oral and Maxillofacial Surgeons.13
Results ARTHROSCOPIC FINDINGS
After adhesion ablation, the adhesion had completely disappeared without floccule. The surface of the disc
and eminence changed color from white to light yellow, with some areas becoming concave. No cartilage damage was found at the surrounding tissue (Fig 2D). After anterior release, the edge of the incision was trimmed, and the color changed from yellow to umber without hemorrhage points. Combined with the suture technique, the disc can be replaced to its normal position. The posterior band of the disc was between the roof of the condyle and the back slope of the eminence when the condyle was in a forward and seated position. After chondroplasty with Coblation, the unhealthy cartilage in the center of the injured areas was removed,
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CHEN ET AL
FIGURE 4. Coblation for chondroplasty. A, Rough surface of cartilage and procedure of trimming with Coblation probe. B, Postoperative smooth surface of cartilage (arrow) without cautery damage and necrosis to adjacent chondrocyte. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
and the inferior healthy cartilage or bone was smooth. The adjacent edge was smooth as well, and no cautery damage was found at the remaining cartilage (Fig 4B). After partial resection of the disc, the margin of the disc was smooth, with no apparent thermal or structural damage to the adjacent synovium, cartilage, or bone tissue. The bone-to-bone contact was observed arthroscopically when the mandible was functioning. POSTOPERATIVE MR FINDINGS
At 1 week after surgery, all patients were re-examined by MR scan. The MR assessment showed excellent results in 85.92% (360/419) (Fig 5), good results in 8.83% (37/419), and poor results in 5.25% (22/ 419). CLINICAL RESULTS
All 352 patients were followed up for 3 months. Of the TMJs, 76.37% (320/419) had excellent results and 16.47% (69/419) had good results. The success rate was 92.84%. Secondary operations were needed in 28 patients (30 TMJs) because the symptoms and/or MR examination findings were not improved, but only 26 patients (28 TMJs) were willing to undergo them. Secondary arthroscopic therapy was performed in 15
TMJs, and the displaced discs were reduced by performing advanced anterior release with Coblation. Open anchoring of disc was performed in 7 TMJs, because the posterior band of the disc was too thick to be reduced through arthroscopic surgery. Another 6 TMJs had to undergo substitution with costochondral grafts because of progressive osteoarthrosis (1.43%). Evidence of masseter muscle atrophy was found in 4 patients (0.95%), but they recovered in 3 to 6 months.
Discussion Despite its small size, the TMJ is functionally complex and anatomically delicate. ID is the most common TMJ problem. It can be defined as an abnormal functional relationship of the disc to the condyle, fossa, and articular eminence. Anterior disc displacement is a common ID. It may be accompanied by adhesions, damage to the articular cartilage, and/or disc perforation. More than 70% of patients with TMJ problems have some form of disc displacement.14-16 According to the clinical signs and arthroscopic findings, Wilkes16 has classified ID into 5 stages.
Table 2. ARTHROSCOPIC PROCEDURES AND WILKES STAGES OF ID
A⫹B A⫹C A⫹B⫹C A⫹B⫹D A⫹B⫹C⫹D B⫹D⫹E Total
Stage II (No. of TMJs)
Stage III (No. of TMJs)
Stage IV (No. of TMJs)
Stage V (No. of TMJs)
Total (No. of TMJs)
3 13 0 0 0 0 16
22 222 39 0 0 0 283
0 18 28 3 11 0 60
0 24 11 4 13 8 60
25 277 78 7 24 8 419
Abbreviations: A, repositioning and suturing of disc; B, adhesion ablation; C, anterior release; D, chondroplasty; E, discoplasty. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
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COBLATION IN TEMPOROMANDIBULAR JOINT SURGERY
FIGURE 5. Evaluation of disc location before and after arthroscopic surgery by MR. A, Anterior displacement of disc (arrow). B, Repositioned disc after surgery; the arrow shows the gap full of synovial fluid after anterior release. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
Those patients who have persistent complaints of pain, clicking, or limited jaw opening may be candidates for surgical intervention. Arthroscopic surgery has significant efficacy and is minimally invasive. Most cases of ID and early-stage osteoarthritis in which conservative management fails can be treated with arthroscopy.11,15 Arthroscopic surgery of the TMJ has become a common procedure, with a great variety of surgical techniques and instruments. Disc-repositioning techniques, capsular release, synovial coagulation, chondroplasty, discoplasty, and fibrous debridement can be performed with manual instruments (forceps, scalpels, scissors, files, probes, and so on) and/or with rotary mechanical shavers, monopolar or bipolar electrocautery, and lasers.4,5,17-22 Although these techniques generally yield acceptable results, there can still be problems, including hemorrhage, roughened joint surfaces, and thermal damage. Coblation, which was introduced in 1995, has been used extensively in orthopedic arthroscopic surgery. The major advantage is its ability to debride tissues very precisely at low temperatures and without inadvertent damage to adjacent tissues. In this study we performed anterior release, ablation of adhesions, chondroplasty, and discoplasty by Coblation. We found that it was more convenient, more accurate, more efficient, and less invasive than traditional hand instruments, rotary mechanical shavers, monopolar or bipolar electrocautery, and lasers. There was no visible hemorrhage or cautery damage found after arthroscopy, and reappearance of a smooth surface occurred. After suturing, the disc was reduced favorably based on complete anterior release with Coblation, and normal anatomy and function were restored as expected. However, on the basis of our experience, 2 points should be paid attention to, during the procedure, to decrease intraoperative and postoperative complications: 1) The depth of anterior release should not be
greater than 5 mm to avoid breakage of larger blood vessels, which do not achieve hemostasis by Coblation, and masticatory muscle nerve injury, which would result in masticatory muscle atrophy. 2) The irrigation fluid should be injected at a continuous and high flow when Coblation is being performed to minimize chondral thermal damage and avoid secondary osteoarthrosis. As a result, signs and symptoms improved, and the success rate was high, at 92.84%. Of course, the clinical results did not mainly depend on the technique of Coblation but depended on the technique of disc suturing. As an assisting technique, Coblation was a minimally invasive method to smooth the surface and release the anterior attachment. Acknowledgment We thank Professor Harry C. Schwartz, Department of Maxillofacial Surgery, Southern California Permanente Medical Group, University of California (Los Angeles, CA), for his helpful comments on this manuscript.
References 1. Chen YC, Lee SH, Saenz Y, et al: Historic findings of disc, end plate and neural elements after coblation of nucleus pulposus: An experimental nucleoplasty study. Spinal J 3:466, 2003 2. Kaplan L, Uribe JW, Sasken H, et al: The acute effect of radiofrequency energy in articular cartilage: An in vitro study. Arthroscopy 16:2, 2000 3. Lu Y, Edwards RB, Kalscheur VL, et al: Effects of bipolar radiofrequency energy on human articular cartilage: Comparison of confocal laser microscopy and light microscopy. Arthroscopy 17:117, 2001 4. Chossegros C, Cheynet F, Gola R, et al: Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation. Br J Oral Maxillofac Surg 34:504, 1996 5. Kaneyama K, Segami N, Sato J, et al: Outcomes of 152 temporomandibular joints following arthroscopic anterolateral capsular release by holmium:YAG laser or electrocautery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:546, 2004 6. Kramer J, Rosenthal A, Moraldo M, et al: Electrosurgery in arthroscopy. Arthroscopy 8:125, 1992
CHEN ET AL 7. Sherk HH, Black JD, Prodoehl JA, et al: The effects of lasers and electrosurgical devices on human meniscal tissue. Clin Orthop Relat Res 14, 1995 8. House HC, House HO: Use of coblation in wrist arthroscopy. Res Outcomes Arthroscopic Surg 4:1, 1999 9. Stetson WB: Time and cost savings of coblation technique in subacromial decompression. Res Outcomes Arthroscopic Surg 3:1, 1999 10. Tasto JP, Ash SA: Current uses of radiofrequency in arthroscopic knee surgery. Am J Knee Surg 12:186, 1999 11. McCain JP (ed): Principles and Practice of Temporomandibular Joint Arthroscopy. St Louis, MO, Mosby, 1996 12. Murakami K, Moriya Y, Goto K, et al: Four-year follow-up study of temporomandibular joint arthroscopic surgery for advanced stage internal derangements. J Oral Maxillofac Surg 54:285, 1996 13. American Association of Oral and Maxillofacial Surgeons: Parameters of care for oral and maxillofacial surgery. A guide for practice, monitoring and evaluation (AAOMS parameters of care 95). J Oral Maxillofac Surg 53:201, 1995 14. Walker RV, Kalamchi S: A surgical technique for management of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 45:299, 1987 15. White RD: Arthroscopy of the temporomandibular joint: Technique and operative images. Atlas Oral Maxillofac Surg Clin North Am 11:129, 2003
2091 16. Wilkes CH: Internal derangement of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 115:469, 1989 17. Kurita K, Ogi N, Toyama M, et al: Single-channel thin-fiber and Nd:YAG laser temporomandibular joint arthroscope: Development and preliminary clinical findings. Int J Oral Maxillofac Surg 26:414, 1997 18. Liesenhoff T, Funk A: Treatment of temporomandibular joint structures by 308-nm excimer laser—An in vitro investigation. Int J Oral Maxillofac Surg 23:425, 1994 19. Mazzonetto R, Spagnoli DB: Long-term evaluation of arthroscopic discectomy of the temporomandibular joint using the Holmium YAG laser. J Oral Maxillofac Surg 59:1018, 2001 20. Moses JJ, Lee J, Arredondo A: Arthroscopic laser debridement of temporomandibular joint fibrous and bony ankylosis: Case report. J Oral Maxillofac Surg 56:1104, 1998 21. Ohnishi M: Arthroscopic laser surgery and suturing for temporomandibular joint disorders: Technique and clinical results. Arthroscopy 7:212, 1991 22. Quinn JH, Stover JD: Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: A supplemental report. J Oral Maxillofac Surg 56: 1237, 1998
Use of Coblation in Arthroscopic Surgery of the Temporomandibular Joint Min Jie Chen, DDS, PhD, MD,* Chi Yang, DDS, PhD, MD,† Shan Yong Zhang, DDS, MS,‡ and Xie Yi Cai, DDS, PhD, MD§ Purpose: To evaluate the effectiveness of Coblation in temporomandibular joint (TMJ) arthroscopic
surgeries and to preliminarily evaluate the clinical effects. Materials and Methods: Arthroscopic Coblation, combined with disc suturing, was performed in 419 TMJs from July 2001 to March 2007 by use of the ArthroCare System 2000 radiofrequency machine (ArthroCare, Sunnyvale, CA). All patients had stage II to V internal derangement, according to the classification of Wilkes. Besides disc suturing, the technique of Coblation was used in procedures of adhesion ablation, anterior release, chondroplasty, and discoplasty. All patients were followed up for 3 months and evaluated based on immediate arthroscopic findings, by clinical examination, and by magnetic resonance imaging examination. Results: During the TMJ arthroscopic surgeries, the adhesion, unhealthy disc, and cartilage were ablated completely. The surface of the cartilage and disc were smooth without cautery damage and hemorrhage. During the clinical follow-up period, 76.37% of TMJs (320/419) had excellent results and 16.47% (69/419) had good results. The success rate was 92.84%. Masseter muscle atrophy occurred in 4 patients, and 30 TMJs required second arthroscopic surgeries or open surgeries. Conclusions: The technique of Coblation has proved to be an effective and minimally invasive option for the treatment of TMJ internal derangement, with advantages such as offering a high degree of precision and control, causing little or no thermal damage to surrounding tissue, leaving smooth anatomic surfaces, and achieving hemostasis of smaller blood vessels. © 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:2085-2091, 2010 Coblation, or “cold ablation,” is a process by which radiofrequency electrical charges are passed through saline solution, producing a plasma (or charged beam of ions) that can be focused very precisely. This ion beam has sufficient energy to break the
Received from the Department of Oral and Maxillofacial Surgery, School of Stomatology, Shanghai Ninth People’s Hospital, and School of Medicine, Shanghai Jiao Tong University, Shanghai, China. *Associate Professor. †Professor. ‡Attending Doctor. §Associate Professor. This study is supported by a grant from the Shanghai Leading Academic Discipline Fund (Y0203), the Science and Technology Commission of Shanghai (080Z2271100). Address correspondence and reprint requests to Dr Yang: Department of Oral and Maxillofacial Surgery, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, 639 Zhizaoju Rd, Shanghai, 200011, People’s Republic of China; e-mail: [email protected] © 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6809-0009$36.00/0 doi:10.1016/j.joms.2009.04.130
molecular bonds within cells, leading to cellular rupture and the dissolution of targeted tissues. Because radiofrequency current does not pass directly through the tissues, Coblation itself is a lowtemperature technique (in the range of 40°C to 70°C).1-3 As a result, Coblation devices break apart and debride targeted tissues at low temperatures, with minimal effects on surrounding tissues. Lasers, electrosurgical units, and other conventional radiofrequency surgical devices use less precise thermal energy to cut or coagulate tissue at temperatures in excess of 400°C.4-7 The heat can penetrate deeply, producing inadvertent damage to surrounding tissues. This ability to produce precise volumetric tissue removal has made Coblation devices very useful for a number of nasopharyngeal airway procedures, urologic and gynecologic procedures, plastic surgery, herniated spinal disc decompression, and arthroscopic procedures in both large and small joints.1-3,8-10 The purpose of this study was to evaluate the use of Coblation in arthroscopic surgery of the temporomandibular joint (TMJ). To our knowledge, this is the first time a follow-up of TMJ Coblation has been reported.
2085
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COBLATION IN TEMPOROMANDIBULAR JOINT SURGERY
Table 1. FOUR MAIN LESIONS IN DIFFERENT STAGES OF ID
Stage II (No. of TMJs)
Stage III (No. of TMJs)
Stage IV (No. of TMJs)
Stage V (No. of TMJs)
Total (No. of TMJs)
16 0 0 0
283 94 0 0
60 31 0 39
60 44 60 27
419 169 60 66
Anterior displacement Adhesion Perforation Chondral damage
Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
Materials and Methods PATIENTS
We studied a consecutive series of 352 patients (419 TMJs) who had been referred to our department because of closed-lock or TMJ pain from July 2001 to March 2007. The patients consisted of 50 males and 302 females with a mean age of 33.3 years (range, 15-72 years). All showed no improvement after conservative therapy. The mean duration of symptoms was 24.1 months (range, 2 months to 20 years). According to clinical examination and magnetic resonance (MR) findings, all patients included in the study were diagnosed with internal derangement (ID). Many had accompanying intra-articular lesions that we believed would benefit from arthroscopic surgery. On the basis of arthroscopic findings, anterior displacement of disc was the main lesion that occurred in each patient, and the other 3 accompanying lesions—adhesion, perforation, and chondral damage— were found in 227 TMJs. Different lesions in different ID stages are shown in Table 1.
the Coblation wand was introduced through the cannula in the anterior recess (Fig 1). Occasionally, they were reversed. The joint was lavaged with saline solution during the whole procedure. After the diagnosis was established, arthroscopic surgery was performed. The main techniques are as follows:
EQUIPMENT
The Coblation device uses bipolar radiofrequency energy (ArthroCare System 2000; ArthroCare, Sunnyvale, CA) whose power is classified into 1 to 9 grades. The probe is at a 0° angle and measures 1.5 mm in diameter. The arthroscopic system includes a 2.3-mm, 0° angle– view Stryker optical system, a Stryker light source (Stryker Corporation, Kalamazoo, MI), and a Sony video recorder and color monitor (Sony Corporation, Minato, Tokyo, Japan). SURGICAL TECHNIQUE
All arthroscopic procedures were performed with the patient under local anesthesia by the same arthroscopist. The triple-channel arthroscopic technique of McCain11 was used. The lateral anterior channels were used for adhesion ablation, anterior release, chondroplasty, and discoplasty. The lateral ear canal channel was used for suturing. The arthroscope was usually introduced through the cannula in the posterior recess of the superior joint space, and
FIGURE 1. The arthroscope and Coblation probe were inserted into 2 cannulas, with the Coblation probe in the anterior recess and the arthroscope in the posterior recess. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
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CHEN ET AL
FIGURE 2. Coblation for adhesion ablation. A, Adhesion in anterior recess of superior joint space. B, Procedure of adhesion release with scissors. C, Procedure of adhesion ablation with Coblation probe. D, Smooth surface of cartilage and disc after operation. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
1. In cases having fibrous adhesions, they are first removed by use of hand instruments (scissors and forceps) or by Coblation (Figs 2A-C). 2. After the condyle is returned to the fossa, the arthroscope is advanced into the anterior recess. Additional local anesthetic is injected through the anterior cannula to avoid deep pain (Fig 3A). 3. The Coblation probe is used to release the anterior attachment of the disc and a portion of the lateral pterygoid muscle. This allows the disc to reduce easily and effectively. The incision line is located approximately 2 to 3 mm anterior to the anterior band of the disc, along the entire medial-to-lateral breadth of the anterior recess (Figs 3B,C). The depth is between 2 and 5 mm. The synovium is incised, and bleeding is coagulated by the Coblation tip until muscle fibers can be seen clearly. A blunt probe is introduced through the anterior cannula to release the muscle further and to reposition the disc (Figs 3D,E). 4. The posterior margin of the disc is sutured, and the position and function of the disc are confirmed. The details of our suturing technique will be described in another article. 5. If there is damaged cartilage, the Coblation probe is used to smooth the surfaces (Fig 4A).
6. A small perforation of the retrodiscal tissue is closed with suturing. A large perforation of the central part of the disc is treated with the Coblation probe. The edges of the disc are trimmed, and degenerative fibrocartilage is removed from the surface of the eminence. The procedures used for different stages of ID are listed in Table 2. EVALUATION
MR imaging examinations 1 week after surgery were performed to evaluate the position of the disc. Results were deemed excellent if all MR sagittal figures of the lateral one third, central one third, and medial one third of the condyle show that the posterior margin of the disc occupies the 11- to 1-o’clock location in relation to the condylar head in the closed-mouth position; good if 2 parts of MR sagittal figures (lateral one third, central one third, and medial one third) show that the posterior margin of the disc occupies the 11- to 1-o’clock location in relation to the condylar head; or poor if only 1 part or none of the MR sagittal figures (lateral one third, central one third, and medial one third) show that the posterior margin of the disc occupies the 11- to 1-o’clock loca-
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FIGURE 3. Coblation for anterior release. A, Local anesthesia to prevent deep pain. B, C, Cutting line located approximately 2 to 3 mm anterior to anterior band of disc, along entire medial-to-lateral breadth of anterior recess, and procedure of releasing anterior attachment of disc and partial lateral pterygoid muscle with Coblation. D, E, Procedure of releasing attachment further and repositioning disc with blunt probe. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
tion in relation to the condylar head. If the result is poor, a second arthroscopic surgery or open surgery can be performed to correct the position of the disc. Clinical criteria were based on data from Murakami et al12 and the American Association of Oral and Maxillofacial Surgeons.13
Results ARTHROSCOPIC FINDINGS
After adhesion ablation, the adhesion had completely disappeared without floccule. The surface of the disc
and eminence changed color from white to light yellow, with some areas becoming concave. No cartilage damage was found at the surrounding tissue (Fig 2D). After anterior release, the edge of the incision was trimmed, and the color changed from yellow to umber without hemorrhage points. Combined with the suture technique, the disc can be replaced to its normal position. The posterior band of the disc was between the roof of the condyle and the back slope of the eminence when the condyle was in a forward and seated position. After chondroplasty with Coblation, the unhealthy cartilage in the center of the injured areas was removed,
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CHEN ET AL
FIGURE 4. Coblation for chondroplasty. A, Rough surface of cartilage and procedure of trimming with Coblation probe. B, Postoperative smooth surface of cartilage (arrow) without cautery damage and necrosis to adjacent chondrocyte. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
and the inferior healthy cartilage or bone was smooth. The adjacent edge was smooth as well, and no cautery damage was found at the remaining cartilage (Fig 4B). After partial resection of the disc, the margin of the disc was smooth, with no apparent thermal or structural damage to the adjacent synovium, cartilage, or bone tissue. The bone-to-bone contact was observed arthroscopically when the mandible was functioning. POSTOPERATIVE MR FINDINGS
At 1 week after surgery, all patients were re-examined by MR scan. The MR assessment showed excellent results in 85.92% (360/419) (Fig 5), good results in 8.83% (37/419), and poor results in 5.25% (22/ 419). CLINICAL RESULTS
All 352 patients were followed up for 3 months. Of the TMJs, 76.37% (320/419) had excellent results and 16.47% (69/419) had good results. The success rate was 92.84%. Secondary operations were needed in 28 patients (30 TMJs) because the symptoms and/or MR examination findings were not improved, but only 26 patients (28 TMJs) were willing to undergo them. Secondary arthroscopic therapy was performed in 15
TMJs, and the displaced discs were reduced by performing advanced anterior release with Coblation. Open anchoring of disc was performed in 7 TMJs, because the posterior band of the disc was too thick to be reduced through arthroscopic surgery. Another 6 TMJs had to undergo substitution with costochondral grafts because of progressive osteoarthrosis (1.43%). Evidence of masseter muscle atrophy was found in 4 patients (0.95%), but they recovered in 3 to 6 months.
Discussion Despite its small size, the TMJ is functionally complex and anatomically delicate. ID is the most common TMJ problem. It can be defined as an abnormal functional relationship of the disc to the condyle, fossa, and articular eminence. Anterior disc displacement is a common ID. It may be accompanied by adhesions, damage to the articular cartilage, and/or disc perforation. More than 70% of patients with TMJ problems have some form of disc displacement.14-16 According to the clinical signs and arthroscopic findings, Wilkes16 has classified ID into 5 stages.
Table 2. ARTHROSCOPIC PROCEDURES AND WILKES STAGES OF ID
A⫹B A⫹C A⫹B⫹C A⫹B⫹D A⫹B⫹C⫹D B⫹D⫹E Total
Stage II (No. of TMJs)
Stage III (No. of TMJs)
Stage IV (No. of TMJs)
Stage V (No. of TMJs)
Total (No. of TMJs)
3 13 0 0 0 0 16
22 222 39 0 0 0 283
0 18 28 3 11 0 60
0 24 11 4 13 8 60
25 277 78 7 24 8 419
Abbreviations: A, repositioning and suturing of disc; B, adhesion ablation; C, anterior release; D, chondroplasty; E, discoplasty. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
2090
COBLATION IN TEMPOROMANDIBULAR JOINT SURGERY
FIGURE 5. Evaluation of disc location before and after arthroscopic surgery by MR. A, Anterior displacement of disc (arrow). B, Repositioned disc after surgery; the arrow shows the gap full of synovial fluid after anterior release. Chen et al. Coblation in Temporomandibular Joint Surgery. J Oral Maxillofac Surg 2010.
Those patients who have persistent complaints of pain, clicking, or limited jaw opening may be candidates for surgical intervention. Arthroscopic surgery has significant efficacy and is minimally invasive. Most cases of ID and early-stage osteoarthritis in which conservative management fails can be treated with arthroscopy.11,15 Arthroscopic surgery of the TMJ has become a common procedure, with a great variety of surgical techniques and instruments. Disc-repositioning techniques, capsular release, synovial coagulation, chondroplasty, discoplasty, and fibrous debridement can be performed with manual instruments (forceps, scalpels, scissors, files, probes, and so on) and/or with rotary mechanical shavers, monopolar or bipolar electrocautery, and lasers.4,5,17-22 Although these techniques generally yield acceptable results, there can still be problems, including hemorrhage, roughened joint surfaces, and thermal damage. Coblation, which was introduced in 1995, has been used extensively in orthopedic arthroscopic surgery. The major advantage is its ability to debride tissues very precisely at low temperatures and without inadvertent damage to adjacent tissues. In this study we performed anterior release, ablation of adhesions, chondroplasty, and discoplasty by Coblation. We found that it was more convenient, more accurate, more efficient, and less invasive than traditional hand instruments, rotary mechanical shavers, monopolar or bipolar electrocautery, and lasers. There was no visible hemorrhage or cautery damage found after arthroscopy, and reappearance of a smooth surface occurred. After suturing, the disc was reduced favorably based on complete anterior release with Coblation, and normal anatomy and function were restored as expected. However, on the basis of our experience, 2 points should be paid attention to, during the procedure, to decrease intraoperative and postoperative complications: 1) The depth of anterior release should not be
greater than 5 mm to avoid breakage of larger blood vessels, which do not achieve hemostasis by Coblation, and masticatory muscle nerve injury, which would result in masticatory muscle atrophy. 2) The irrigation fluid should be injected at a continuous and high flow when Coblation is being performed to minimize chondral thermal damage and avoid secondary osteoarthrosis. As a result, signs and symptoms improved, and the success rate was high, at 92.84%. Of course, the clinical results did not mainly depend on the technique of Coblation but depended on the technique of disc suturing. As an assisting technique, Coblation was a minimally invasive method to smooth the surface and release the anterior attachment. Acknowledgment We thank Professor Harry C. Schwartz, Department of Maxillofacial Surgery, Southern California Permanente Medical Group, University of California (Los Angeles, CA), for his helpful comments on this manuscript.
References 1. Chen YC, Lee SH, Saenz Y, et al: Historic findings of disc, end plate and neural elements after coblation of nucleus pulposus: An experimental nucleoplasty study. Spinal J 3:466, 2003 2. Kaplan L, Uribe JW, Sasken H, et al: The acute effect of radiofrequency energy in articular cartilage: An in vitro study. Arthroscopy 16:2, 2000 3. Lu Y, Edwards RB, Kalscheur VL, et al: Effects of bipolar radiofrequency energy on human articular cartilage: Comparison of confocal laser microscopy and light microscopy. Arthroscopy 17:117, 2001 4. Chossegros C, Cheynet F, Gola R, et al: Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation. Br J Oral Maxillofac Surg 34:504, 1996 5. Kaneyama K, Segami N, Sato J, et al: Outcomes of 152 temporomandibular joints following arthroscopic anterolateral capsular release by holmium:YAG laser or electrocautery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:546, 2004 6. Kramer J, Rosenthal A, Moraldo M, et al: Electrosurgery in arthroscopy. Arthroscopy 8:125, 1992
CHEN ET AL 7. Sherk HH, Black JD, Prodoehl JA, et al: The effects of lasers and electrosurgical devices on human meniscal tissue. Clin Orthop Relat Res 14, 1995 8. House HC, House HO: Use of coblation in wrist arthroscopy. Res Outcomes Arthroscopic Surg 4:1, 1999 9. Stetson WB: Time and cost savings of coblation technique in subacromial decompression. Res Outcomes Arthroscopic Surg 3:1, 1999 10. Tasto JP, Ash SA: Current uses of radiofrequency in arthroscopic knee surgery. Am J Knee Surg 12:186, 1999 11. McCain JP (ed): Principles and Practice of Temporomandibular Joint Arthroscopy. St Louis, MO, Mosby, 1996 12. Murakami K, Moriya Y, Goto K, et al: Four-year follow-up study of temporomandibular joint arthroscopic surgery for advanced stage internal derangements. J Oral Maxillofac Surg 54:285, 1996 13. American Association of Oral and Maxillofacial Surgeons: Parameters of care for oral and maxillofacial surgery. A guide for practice, monitoring and evaluation (AAOMS parameters of care 95). J Oral Maxillofac Surg 53:201, 1995 14. Walker RV, Kalamchi S: A surgical technique for management of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 45:299, 1987 15. White RD: Arthroscopy of the temporomandibular joint: Technique and operative images. Atlas Oral Maxillofac Surg Clin North Am 11:129, 2003
2091 16. Wilkes CH: Internal derangement of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 115:469, 1989 17. Kurita K, Ogi N, Toyama M, et al: Single-channel thin-fiber and Nd:YAG laser temporomandibular joint arthroscope: Development and preliminary clinical findings. Int J Oral Maxillofac Surg 26:414, 1997 18. Liesenhoff T, Funk A: Treatment of temporomandibular joint structures by 308-nm excimer laser—An in vitro investigation. Int J Oral Maxillofac Surg 23:425, 1994 19. Mazzonetto R, Spagnoli DB: Long-term evaluation of arthroscopic discectomy of the temporomandibular joint using the Holmium YAG laser. J Oral Maxillofac Surg 59:1018, 2001 20. Moses JJ, Lee J, Arredondo A: Arthroscopic laser debridement of temporomandibular joint fibrous and bony ankylosis: Case report. J Oral Maxillofac Surg 56:1104, 1998 21. Ohnishi M: Arthroscopic laser surgery and suturing for temporomandibular joint disorders: Technique and clinical results. Arthroscopy 7:212, 1991 22. Quinn JH, Stover JD: Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: A supplemental report. J Oral Maxillofac Surg 56: 1237, 1998