This seminar explains about the development, relations, ligaments, various attachments, vascular and nervous supply and various surgical approaches and its modifications to TMJ

1. Dr. VIJAYA LAKSHMI.G
I MDS
Dept. of OMFS

2. • INTRODUCTION
• DEVELOPMENT OF TMJ
• PECULIAR FEATURES
• ARTICULATORY SYSTEM
• COMPONENTS
- Articular Eminence
- Glenoid Fossa
- Condyle
- Articular Disc
- Ligaments
- Muscular Components

3. • Vascular supply
• Nerve innervation
• Relations of the TMJ
• Age changes in TMJ
• Structures injured during surgery
• Associated surgical anatomy
• Surgical approaches to TMJ and their modifications
• Complications
• Conclusion
• References

4. • Ginglymoarthrodial joint
ginglymus : hinge joint
arthrodia : gliding motion
• Craniomandibular joint
• Complex joint

5. Early TMJ develops from the 1st branchial arch
mesenchyme
Early embryonic joint:
 Between malleus and incus (from 1st
branchial arch)
 Primary TMJ till 16 weeks of IUL
Uniaxial hinge joint capable of no lateral
motion.

6. • End of 7-11 weeks: 20 TMJ begins to
develop .
• 9th week– a condensation of mesenchyme
appears surrounding the upper posterior
surface of rudimentary ramus
( joint capsule develops from the condensed
mesenchyme)
10-12 weeks of IUL, both blastema grows
towards each other
10th week- two clefts - forming the two joint
cavities -intervening articular disc
Upper compartment starts to appear: 111/2
weeks

8. The TMJ develops from 2 blastemas:
a) temporal blastemas arise from the otic capsule
b)The condylar blastema arises from the secondary cartilage of the mandible

9. Intra articular disc: well defined by 16th week of IUL
At birth: mandibular fossa :
- flat (no articular eminence)
- prominent after eruption of 10 dentition
Developing disc- highly cellular & vascular. (vessels disappear by 3 years of age)
Attachments of fetal disc: rich in elastic fibers.
Joint components mature by 14th week of IUL

10. Fetal disc:
- nerve fibers & blood vessels in periphery.
- disappear but remain at the disc attachment after birth.
- In center of condyle, cartilage develops.
- Remains as 20 cartilage upto 27yrs of age
Adaptive changes:
Condyle enlargement in adulthood (in response to overloading)

11. • Bilateral diarthrosis
• Articular surface covered by fibrous cartilage instead of hyaline cartilage
• It is the only bilateral joint that crosses the midline.
• Only joint in human body with rigid end point ,due to occlusion
• In contrast to other diarthroidal joints, TMJ is last to develop
(i.e., in about 7th week of uterine life)
• TMJ develops from distinct blastema
The effect of distraction on the temporomandibular joint
Suzanne U. Stucki-McCormick

12. Regional adaptive growth center for growth & development of mandible & middle
3rd of face
Trauma Retrognathia

13. A) Upper articular surface:
• Articular tubercle
• Anterior part of the mandibular fossa
• Posterior non-articular part formed
by tympanic plate

14. B) Lower articular surface:
Head of mandible

15. • ARTICULAR EMINENCE
• MANDIBULAR FOSSA
• CONDYLE
• ARTICULAR DISC
• LIGAMENTS
• MUSCULAR COMPONENT

16. ARTICULAR
EMINENCE
• Transverse bony bar that forms the anterior root of
zygoma.
• Most heavily travelled by the condyle and disk as they ride
forward and backward in normal jaw function.
ARTICULAR
TUBERCLE
• small, raised, rough, bony knob on the outer end of the
articular eminence.
• Projects below the level of the articular surface
• Serves to attach the lateral, collateral ligament of the joint.

17. PREGLENOID
PLANE
• Slightly hollowed, almost horizontal, articular
surface continuing anteriorly from the height
of the articular eminence.

18. E: Articular eminence
Enp: entogolenoid process
t: articular tubercle
Gf: Glenoid fossa
lb: lateral border of the mandibular
fossa
pep: preglenoid plane

19. GLENOID FOSSA-
 separates the joint from
middle cranial fossa
 Lined by:
dense avascular fibrocartilage
 Cross section:
fossa & eminence form ‘Lazy S’ PA
 Sqamotympanic fissure
separates it from tympanic plate,
forms a posterior wall of glenoid fossa

20. Parts:
A) Medial rim:
lateral to : - spine of sphenoid &
- foramen spinosum (middle meningeal artery)
B) Lateral rim continues:
- anteriorly into zygomatic tubercle
(which can be felt under the skin )
- posteriorly into postglenoid tubercle

21. CLINICAL SIGNIFICANCE:
 Chorda tympani nerve appears at the medial end of petro tympanic fissure
close to spine of sphenoid.
 Roof of fossa is thin (separates brain from joint) – avoid perforation of roof
during surgery of roof.
Melugin MB et al. 1997 55;11: 1342-1347 Glenoid fossa fracture
and condylar penetration into the middle cranial fossa: Report
of a case and review of the literature

22.  Important surgical landmark during dissection down to the joint from
a preauricular approach.
 Posteromedially: contents of the middle ear, damaged by injudicious
surgery

23. CONDYLE -
 Elliptical shape
 Long axis:15-330 to frontal plane
900 to body of mandible

24.  It has a medial and lateral pole
 The medial pole is directed more posteriorly
 Thus, if the long axes of two condyles are extended medially,
meet at approximately the basion on the anterior limit of
foramen magnum, forming an angle that opens toward the front ranging
from 145° to 160°

25. Anterior aspect
Mediolateral length – 15-20mm
Poster superior aspect
Anteroposterior width- 8 to 10 mm

26. Mainly 4 shapes are seen-
1. Convex-58%
2. Flat- 25%
3. Pointed-12%
4. Round- 3%
( mainly in children)

27. ARTICULAR DISC-
 Biconcave (sagittal)
 fibrocartilagenous
 non-innervated
(except around periphery)
 Avascular collagen
 flexible

28.  Articular space:
A) Upper compartment
* Gliding movement
B) Lower compartment
* Hinge/Rotation
* Gliding movement

29. 3 zones:
 Anterior band (2mm)-
Narrow anteroposteriorly
 Posterior band: 3mm –
Thickest and widest
 Intermediate zone: 1mm (thinnest)
 More posteriorly: bilaminar or retrodiscal region

30. Disc stabilized on condyle by:
a) Disc edges fused with the part of the capsular ligament that tightly
surrounds the lower joint compartment.
b) Well-defined bands in the capsular ligament attach the disc to the
medial and lateral poles of the condyle.
- Thick anulus prevents the disc sliding off the condyle, provided that
the condyle and disc are firmly lodged against the articular fossa

31.  Anterior:
- Confluent with capsule,
fascia of lateral pterygoid
(Superior head)
 Posterior:
- retrodiscal tissue

32. The TMJ disc displays viscoelastic material properties that are related to its ECM components.
-TMJ disc is observed to be 100-1000 times stiffer under tension than compression.
Compression-The compressive properties of the disc may be contributed by both GAG and collagen.
Tension-
The disc frequently experiences tensile forces during normal joint movements.
At strains of 0-2%, the instantaneous elastic modulus of the healthy TMJ disc is 44 MPa, compared to 53
MPa for internally deranged tissue.
MECHANICAL PROPERTIES -

33. JOINT IN POSITION-
a) Primary proprioceptors
(Golgi tendon organs)
b) Encapsulated mechanoreceptors

35. Malleo mandibular ligament (Pinto’s ligament)
- Most medial portion of disc is connected posteriorly to PINTO’s
ligament
 vascular
 innervated
 fibro elastic

36. Function:
 Shock absorber (less friction & heat production)
 Designed to transmit forces generated through the condyle to the articular
eminence
 Protection for bony components
 Promotes lubrication
 Stabilizes the condyle against the temporal articulation

37. VASCULAR KNEE-
 Above Posterosuperior aspect of condyle & anterior to bilaminar zone,
disc is vascular.
 Anterior extensions of disk at its attachment to superior belly of
lateral pterygoid is also vascular.

39. CAPSULE-
Attached :
Above to rim of glenoid fossa &
articular eminence
Below to periosteum of neck of condyle

40. ATTACHMENTS OF CAPSULE-
 Anterolaterally : articular tubercle
 Laterally : lateral rim of the mandibular fossa
 Posterolaterally : postglenoid process
 Posteriorly : posterior articular ridge
 Medially : medial margin of the temporal fossa
 Anteriorly : preglenoid plane

41. Relations:
(Medially)-
1) Spine of Sphenoid
2) Sphenomandibular ligament
3) Middle meningeal artery
(through Foramen Spinosum)

42. Lateral retraction of capsule allows access to upper joint space.
FUNCTION:
 On the lateral part of the joint, capsule functionally limits the forward
translation of the condyle.
 Medially and laterally- blends with the condylodiscal ligaments

43. • Anteriorly, the capsule has an orifice through which the lateral pterygoid
tendon passes
• This area of relative weakness in the capsular lining becomes a source of
possible herniation of intra-articular tissues, may allow forward displacement
of the disk

44. CLINICAL SIGNIFICANCE:
 Extension of a lateral capsular incision cause severe bleeding if not
cautious.

45.  During Preauricular incision ( expose lateral aspect of TMJ),
protect temporal branch of facial nerve by having the
dissecting plane under superficial layer of deep temporalis
fascia until root of zygomatic arch is reached
 Reflect tissue close to periosteum & desend inferiorly to
expose the entire lateral capsule
 Parotid is usually found between posterior capsule and postglenoid tubercle.
Extends till it reaches lateral wall of pharynx.
 Enlargement of Parotid can impinge on posterior capsule of TMJ & cause pain
during closure of mouth or during chewing movements

46. LATERAL/TM LIGAMENT-
- Main stabilizing ligament
- Thickened capsule
- Collagen fibers
- Course:
 Down & back
 Attached above to articular eminence
 Below to outer & post side of neck of condyle
 Posterior fibers unite with capsule

47. Function:
 Limits protraction
 Inferior distraction
 Posterior movement of condyle
 Specific length & poor ability to stretch- maintains integrity & limits movement
of TMJ (mainly anterior excursion & prevents posterior dislocation – CHECK
LIGAMENT
Slippage of condyle:
a) medially prevented by Glenoid process
b) laterally by TM ligament

48. COLLATERAL /DISCAL LIGAMENT-
 Attach medial & lateral borders of articular
disc to the poles of the condyle.
 True ligament
(collagen i.e. don’t stretch)
Function:
• Restrict movement of disc away from condyle (allow disc to move passively
with condyle as it glides anteriorly & posteriorly)
• Hinge movement

49. 1) SPHENOMANDIBULAR LIGAMENT:
Arises:
from spine of sphenoid
Inserted into:
Lingula of mandible

50. RELATIONS-
1. Laterally- lateral pterygoid muscle
2. Posteriorly- auriculotemporal nerve
3. Anteriorly- maxillary artery
4. Inferiorly- the inferior alveolar nerve & vessels, a lobule of the parotid
gland
5. Medially- medial pterygoid with the chorda tympani nerve and the wall
of the pharynx with fat and the pharyngeal veins intervening

52. • The ligament is pierced by the
mylohyoid nerve and vessels
• This ligament is passive during jaw
movements, maintaining relatively the
same degree of tension during both
opening and closing of the mouth

53. 1. Internal Maxillary artery
2. Auriculotemporal nerve lies
between it & neck of mandible.
3. Chorda tympani branch of facial
nerve crosses the ligament at the
upper end.
Important landmark during surgery:

54. SIGNIFICANCE-
a) forms broad impermeable wall
medial to mandibular foramen.
During IANB ,it holds LA concentrated against the nerve and prevents
fluid from dissipating into adjacent soft tissue.
b) Loose areolar tissues present in it, during blunt dissection, help define
the posterior limits of capsule.
It can cause abundant venous hemorrhage.

55. 2) STYLOMANDIBULAR LIGAMENT-
 Thick deep cervical fascia
 Origin: Styloid process
 Insertion: Angle of mandible
Function:
 Restrict movement of disc away from condyle
 Hinge movement

56.  Sources:
1) from plasma by dialysis
2) secretion synoviocytes
type A and B
Upper compartment - 1.2 ml
Lower compartment - 0.9 ml

57. Composition:
a) Hyaluronic acid - viscous
b) Lubricin – (glycoprotein):
 lubricates
 reduces friction b/w articular surfaces of joint
c) Mucin

58. SIGNIFICANCE-
 Synovial hyperplasia seen in Rheumatoid arthritis, causes severe pain
 Fluid exists under –ve intra-articular pressure
 ↑ in pressure: factor in pathogenesis of Osteoarthritis & cause pain

59. FUNCTION:
- Nutrition
- Phagocytosis
- Lubrication

61.  Lateral pterygoid muscle attachments are of surgical significance, since it is
not possible to remove the head of the condyle without sectioning the insertion
 Where reattachment does not take place, some joint function is lost and
deviation of the jaw occurs when opening widely.

62. Limits rotation of condyle
(20-25mm)
Translation Beyond 25 mm

63. Lateral movements:
 Medial & Lateral pterygoid
Hinge movement:
 Geniohyoid
 Anterior belly of Digastric
Translatory :
 lateral pterygoid

64.  Stable occlusion- Five requirements
 centric jaw relation
 immediate front teeth separation,
 proper cusp–fossa relationship,
 stable/even bite, and
 proper space (volume) inside the mouth.
 Instability : ↑ pressure on the joint
damage & degeneration
The Relationship Between Dental Occlusion/Temporomandibular Joint Status and General
Body Health: Part 1. Dental Occlusion and TMJ Status Exert an Influence on General Body
Health Hyung-Joo Moon, DDS, MSD, PhD,1 and Yong-Keun Lee, DDS, MSD, PhD1,2

66. Lateral aspect of capsule:
 Superficial temporal artery
-Deep & posterior aspect of retrodiscal capsular part
 Branches of Internal Maxillary artery
( Deep auricular
Posterior auricular,
Massetric branches)
 The blood supply to TMJ is only superficial,
no blood supply inside the capsule
 TMJ takes its nourishment from Synovial fluid

67.  Venous plexus around capsule
 Maxillary vein
 Transverse facial vein
 Superficial temporal vein

68.  Auriculo temporal nerve –
- posterior,
- medial
- lateral parts of the joint
 Massetric nerve
 Branch from posterior deep temporal nerve for anterior parts of joint

69. Anteriorly-
- Mandibular notch
- Lateral pterygoid
- Masseteric nerve and artery

70. Posteriorly- Parotid gland
- Superficial temporal vessels
- Auriculotemporal nerve

71. Laterally-
- Skin and fascia
- Parotid gland
- Temporal branches of facial nerve
Medially-
- Tympanic plate (separates from ICA)
- Spine of sphenoid
- Auriculotemporal & chorda tympani nerve
- Middle meningeal artery
- Maxillary artery

72. Superiorly–
Middle cranial fossa
Middle meningeal vessels
Inferiorly–
Maxillary artery & vein

73.  Condyle:
◦ More flattened
◦ Fibrous capsule : thicker
◦ Osteoporosis
◦ Thinning or absence of cartilaginous zone
 Articular Disc:
◦ Thinner
◦ Hyalinization

74. DEVELOPMENTAL
* Agenesis
* Hyperplasia
* Hypoplasia
TRAUMATIC
* Fracture
* Dislocation
* Ankylosis
INFLAMMATORY
Eg: Rheumatoid arthritis
Ankylosing spondylitis
Gout
NEOPLASTIC
A) BENIGN – Chondroma
B) MALIGNANT –
Chondroblastoma
Chondrosarcoma
INFECTIOUS
Eg : Spread from TB,
Syphilis
DEGENERATIVE
CONDITION
Eg: Osteoarthritis
Rheumatoid arthritis
Still’s disease

75.  Dislocation – forward
Reduction is prevented by spasm of elevators (Masseter, Temporalis,
Medial Pterygoid) hold the dislocated jaw open with condyle in front of
eminence.
 Rx: operators thumbs pressing down on molars or alveoli, before the
condyle can be guided back into the fossa.

76.  Facial nerve
 Auriculotemporal nerve
 Bleeding from medial aspect of the condylar head
* Lateral pterygoid
* Internal maxillary artery

78. FACIAL NERVE-
Distance from the lowest concavity of the external auditory canal to the bifurcation of the
main trunk of the facial nerve- 1.5 to 2.8 cm
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed

79. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
From the bifurcation of the facial nerve to the post-glenoid tubercle-
2.4 to 3.5

80. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
The distance from the most anterior concavity of the bony external auditory
canal to the most posterior significant temporal branch of the facial nerve- 0.8-3.5
cm (mean 2 cm)

81.  Liebman et al in 1982, described histologically that the layer in
which it travels.
They reported that it was locked in the fascial layer between
temporalis fascia and subdermal fat superficially.
 Stuzin et al in 1988, examined the temporal region by cadaver dissection and
reported that it lay within the temporoparietal fascia and travels along
undersurface of this fascial layer.

82. A straighttrajectory A curved trajectory
Temporal branches of Facial nerve
IshikawaY:An anatomical study on the distribution of the temporal branch of the facial nerve.

83. Pitanguy, L, A. S. Ramos:
The frontal branch of the facial
nerve: The importance of its
variation in face lifting.
Middelton’s line
Plast. Reconstr. Surg. 38 (1966) 352

84. The new guideline for
preservation of the entire
temporal branch is drawn
with a dashed line.
J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
An anatomical study of the distribution of temporal branch of facial nerve

85. J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
An anatomical study of the distribution of temporal branch of Facial
Nerve

86. Dingman
and Grab
Ziarah and
Atkinson

87. SURGICAL ANATOMY OF MANDIBULAR DISTRIBUTION OF
FACIAL NERVE.ZIARAH & ATKINSON, BJOS 1981;19,159-170

88. Superficial
temporal artery
Transverse facial
artery
Maxillary artery
Atlas of human anatomy – Frank H Netter 6th ed

89. Arises from posterior part of mandibular division of CN V
Atlas of human anatomy – Frank H Netter 6th ed
Runs beneath lateral pterygoid muscle.
Passes from medial surface of condyle &
emerges on to the face behind the TMJ within the
superior surface of the parotid gland.
Ascends posterior to the superficial temporal
vessels, passes over the posterior root of the
zygoma, and divides into superficial temporal
branches.

90. Superficial temporal
vein
Maxillary vein
Retromandibular vein
Anterior division
Posterior
division
GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed

91. Largest ascending branch of the
cervical plexus
Greater auricular
arises from the second and third cervical rami,
encircles the posterior border of
sternocleidomastoid,
perforates the deep fascia and ascends on the
muscle beneath platysma
On reaching the parotid gland, it divides into anterior
and posterior branches

92.  Temporomandibular joint and its components frequently require
exposure for a myriad of procedures.

93. Coronal section of the temporomandibular
joint (TMJ) region.

94.  Concept given by Teisser & defined by Mitz and
Peyronie in 1976.
 Continuous fibromuscular layer.
 Synonyms:
 In scalp– galea aponeurotica
 In temporal region – temporoparietal fascia,
superficial temporal fascia or suprazygomatic
SMAS
 Below zygomatic arch –
parotideomasseteric fascia

95. Extra oral approaches
1. Preauricular
2. Endaural
3. Postauricular
4. Coronal
5. Retromandibular
6. Submandibular
7. Rhytidectomy
Intraoral approaches
1.Intraoral vestibular –
-without endoscope
-with endoscope

96.  Accessibility to the joint
 Avoiding damage to vital neurovascular structures
 Aesthetic concerns on visibility of post op scars
 Technique sensitivity and surgeon’s experience
 In case of ankylosis, choice of interpositioning material.

97. Surgical approaches to facial skeleton – Edward Ellis 2nd ed

98. Incision is outlined at the junction of facial skin and helix of
the ear.
• Incision usually is 3-4 cm in length consist of 2 limbs- superior curved limb and inferior vertical limb
anterior to tragus.
• Initial incision is made through skin and subcutaneous tissue.

99. Surgical approaches to facial skeleton – Edward Ellis 2nd ed
DISSECTION

102. Incision through the lateral attachment of the temporomandibular joint disk, entering the
inferior joint space. A:Illustration showing use of sharp scissors to incise the lateral
attachment of the disk.
B: Photograph showing a scalpel used for the same purpose.

104. Suprafascial procedure
-Rowe NL: Surgery of the temporo-mandibular
Joint. Proc R Soc Med 65:383, 1972
Subfascial procedure
-Al-Kayat A, Bramley P: Amodified pre-auricular
approach to the temporomandibular joint and
malar arch. Br J Oral Surg 17:91, 19
Deep SubfascialApproach
- Massimo Politi : J Oral Maxillofac Surg
62:1097-1102, 2004
Preauricular dissection techniques described in
literature

105. Politi et al. Deep Subfascial Approach to the TMJ. J Oral Maxillofac Surg 2004

106. Blair’s Inverted
Hockey Stick
Dingman’s Incision Endaural Incision
Popowich and Crane
Incision
Thoma’s Angulated
Incision

107. Skin incision is question mark shaped
A modified pre-auricular approach to the temporomandibular joint and malar arch
British Journal of Oral Surgery 17 (1979-80), 91-103
Begins antero-superiorly within the
hairline & curves backwards and
downwards well posterior until it
meets upper ear attachment
Incision then follows ear
attachment endauraly

108. Advantages:
• less bleeding
• Fascial planes can be easily
identified
• Excellent visibility
• good cosmetic
result
10
7-Mar-
17

109.  Incision is started in the fold at the junction of
anterior margin of helix
 Carried downwards to upper portion of tragus
where it is contained inside the margin of tragus
to anterior fold of lobule
 It again becomes visible at this point and is
carried downwards to lower attachment of ear

111. First described by Lempart as an approach to
mastoid process for surgical improvement of
otosclerosis, for approaching TMJ.

112. Incision begins well within the EAM at
superior meatal wall
The incision is carried carefully through the skin over
the tragal cartilage at a 90- degree angle to the most
convex part of the tragus itself.
The incision is carried superiorly to the uppermost
portion of the auricle and then extends in
approximately a 45 degree angle into the temporal
hairline for about 3 to 4 cm.

113. • Incision is deepened to temporoparietal
fascia continued inferiorly with knife in
continuous contact with the tympanic
plate.
• Sharp dissection is done along the
perichondrium and the flap is raised en
masse anteroinferiorly.

114. Comparison of standard preauricular
and endaural surgical approaches
Advantages:
• Most of the vital structures are in a superficial plane.
• Very good access to the joint and also the
coronoid process.
• Excellent esthetic result with minimal post
operative scar
Disadvantages:
• Esthetic compromise if tragal projection is lost
• Risk of possible perichondritis
7-Mr-
17

115. A modified endaural approach to the TMJ
J ORAL MAXILLOFAC SURG 51:33-37,1993
• Broad based flap with excellent
blood supply
• Possibility of residual cartilaginous
deformity is less
• Damage to CN VII is unlikely
ADVANTAGES-

116.  Descibed by Alexander & James
 Incision is placed in the grove between the helix
and post auricular skin
 Pre-op considerations described by Walter and Geist:
1. History of normal scar formation
2. Healthy auditory system with no infection
3. No TMJ infection

117. 3-5cm incision is made parallel & posterior
to postauricular flexure
Begins at superior aspect of external
pinna and extended till the tip of mastoid
process
Dissection is done through posterior
auricular muscle to the level of mastoid
fascia
The Post-Auricular approach for Gap Arthroplasty a Clinical Investigation
Journal of Cranio- Maxillo-Facial Surgery 40(2012) 500-505

118. ADVANTAGES
 Predictability of anatomic exposure
 excellent surgical exposure of the
bilaminar zone and the mandibular
condyle posteriorly
 Cosmetic superiority
 Less risk of CN VII injury
 Dissection is more rapid
DISADVANTAGES
 Not advised in patients
susceptible to keloid
 Infection
 Meatal stenosis can occur
 Anterior exposure is limited

119.  Versatile surgical approach to the upper and middle regions of the facial
skeleton, including the zygomatic arch and TMJ.

121. 7-Mar-
17
5
7
LAYERS OF
THE
SCALP
BELOW
THE
SUPERIOR
TEMPORAL
LINE

122. 7-Mar-
17
5
8
Incision placement for patients with male
pattern hair recession. The incision is stepped
posteriorly just above the attachment of the
helix of the ear
Incision placement for most female patients.
The incision is kept approximately
4 cm behind the hairline

123. The incision is through the skin, subcutaneous tissue, and galea revealing the
subgaleal plane of loose areolar connective tissue overlying the pericranium.

124. 12
7-Mar-
17

125. The skin incision below the superior
temporal line should extend to the
depth of the glistening superficial
layer of the temporalis fascia,
into the subgaleal plane, continuous
with the dissection above the superior
temporal line.

126. 7-Mar-
17
6
3
Along the lateral aspect of the skull, the
glistening white temporalis fascia becomes
visible where it blends with the pericranium at
the superior temporal line.
The plane of dissection is just superficial to
this thick fascial sheet

127. Near the ear, the flap is dissected
inferiorly to the root of the
zygomatic arch by incising
superficial layer of temporalis
fascia
The lateral portion of the
flap is dissected inferiorly
atop the temporalis fascia

128. Exposure of the Temporomandibular Joint:
• Access to the TMJ region is gained by dissecting below the zygomatic arch anterior
to tragal cartilage.
• Masseter is detached from the zygomatic arch exposing the sigmoid notch and
TMJ capsule.
• Capsule is then incised exposing the TMJ.

129. CLOSURE: done in layers
 Closure of TMJ capsule is done followed by closure of temporalis
fascia .
 Superficial layer of the temporalis fascia, which is incised during the
approach, is sutured approximately 1 cm superior to the superior edge of
the incised fascia.
 Galea is closed as a distinct layer.
 Scalp incision is closed.

130. The principal difference involves the position of the skin incision
• placed behind the ear.
• use of a zigzag incision instead of a straight incision within the hairline.
Advantage: further camouflage of the scar

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132. 6
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135. Associated anatomic structures

136. Dissection is performed through the
fascia at the level of the initial skin
incision, followed by dissection
superiorly to the level of the
periosteum of the mandible

137. The pterygomasseteric sling is
sharply incised with a scalpel along
the inferior border

138. Closure is done in multiple layers-
Masseter and medial pterygoid muscles
are sutured together
↓
Platysma is closed
↓
Subcutaneous tissues
↓
Skin
CLOSURE-

139.  Exposes the entire ramus from behind the
posterior border.

140. ADVANTAGES: close proximity to the condylar area
DISADVANTAGES:
Passing through the parotid gland tissue, thus increasing the risk of facial nerve
injury and salivary fistulae.

141. Important structures encountered

142. Main Landmarks should be visible-
• Ear
• Lower lip
• Corner of the mouth
Incision-
Begins 0.5 cm below the ear lobe and continues inferiorly 3-3.5 cm just behind the
posterior border of the mandible

144. Blunt
dissection

147. Sigmoid notch retractor. The curved flange at the
end is inserted into the sigmoid notch, retracting
the masseter muscle.

148. J ORALMAXILLOFACSURG 67:2418-2424, 2009

149. 1. Smaller scar as access was limited to 2cm only.
2. Plane of dissection was superficial to SMAS.
3. Risk of Frey’s syndrome, sialocoele and salivary fistula can be
eliminated.
4. Surgical site is always perpendicular to fracture site.
5. Integrity of joint is always maintained.
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ADVANTAGES-

150. Novel Retro mandibular Sub-parotideomasseteric Fascial
approach for placement of a TMJ prosthesis

151.  Also called as facelift approach.
 Variant of retromandibular, transmasseteric -anteroparotid approach
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152.  When using the rhytidectomy approach, the structures that should be visible
in the field include –
1. the corner of the eye,
2. the corner of the mouth, and the lower lip anteriorly,
3. the entire ear and descending hairline, and 2 to 3 cm of hair superior to the
posterior hairline, posteriorly
4. the temporal area must also be completely exposed superiorly
LANDMARKS FOR DRAPING

153. The incision begins approximately
1.5 to 2 cm superior to the zygomatic arch
just posterior to the anterior extent of the
hairline.
The incision then curves posteriorly and
inferiorly, blending into a preauricular
incision in the natural crease anterior to the
pinna.
The incision continues under the earlobe and
approximately 3 mm onto the posterior
surface of the auricle instead of continuing in
the mastoid–ear skin crease.
It curves posteriorly toward the hairline and
then runs along the hairline, or just inside it,
for a few centimeters.

157. Closure

159. Mandibular Vestibular Approach
Advantages-
-Ability to constantly assess the dental occlusion during surgery.
- Greatest benefit- hidden intraoral scar.
-approach is also relatively rapid and simple
Disadvantages-
Access is limited in the lower border of the mandible at the angle and parts of the ramus.
Complications are few but include mental nerve damage and lip malposition, both of which are
minimized with the use of proper technique.

160. Gap arthroplasty for temporomandibular joint ankyloses by trans oral approach:
A case series
Int. J. Oral Maxillofac Surg

161. ADVANTAGES:
• better visibility
• access to high level fracture
using transbuccal trocar.
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162.  Once the capsule has been identified, access to the articular surfaces
(superior and inferior joint spaces) can be obtained by a great variety of
incisions.

163. The lateral ligament, capsule, and
periosteum are reflected inferiorly en
masse.
Discal or posterior attachment are
dissected sharply with scissors to the level
of the condylar neck.
Horizontal incision over the lateral rim of the glenoid
fossa

164. The posterior attachment and disc attachments are then severed sharply at the lateral
pole of the condyle from within the developed flap.
These tissues are then reflected superiorly from the head of condyle to expose
inferior joint space

165. The superior joint space is punctured at
the level of discocapsular sulcus.
A dissection is then carried inferiorly
removing the attachment of the capsule
to the disc and exposing the inferior joint
space.
Horizontal incision below the lateral rim of the glenoid
fossa

166. Horizontal incisions above and below the disc

167. T- Shaped Incision

168. 1. Poor facial scar
2. Infection
3. Wound dehiscence
4. Facial nerve palsy
5. Perichondritis
6. Sialocoele
7. Frey’s syndrome

170. Eyes closed with minimum effort
At rest
Eyebrows raised
Eyes tightly closed
Rowe’s incision
Maximum mouth opening

171. According to House-Brackmann grading system, at 24 h, 78.9% patients had different
grades of facial nerve injury, which gradually improved and came to normal limits within 1-3
months post-operatively.
Conclusion-
The degree of temporary nerve injury could be either due to the heavy retraction
causing compression and or stretching of nerve fiber resulting in neuropraxia.

172. SYMPTOMS:
Pain over auricle and deep in ear canal, edema, erythema, induration

173. MANAGEMENT:
1. Conservative: mildest form is treated by using oral and topical
antibiotics.
2. Hematoma of the auricle should be drained properly
3. If there is any sign of pus drainage – C/S followed by broad
spectrum IV antibiotics.
4. In resistant cases, continuous drainage and irrigation with antibiotics
and steroids solution.
5. In severe cases, aggressive excision of the necrosed cartilage involving
overlying subcutaneous tissues and skin should be done.

174.  Sialocoeles result in the
accumulation of saliva in
glandular/periglandular or
subcutaneous tissues.
 When the accumulated
saliva drain through the
skin it is termed as salivary
fistula.

175. 1. Small sialocoeles have said to resolve spontaneously by scar
formation which seals the salivary flow.
2. Non surgical management:
 repeated aspirations
 compression dressings
 administration of anticholinergic and antisialogogues
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MANAGEMENT:

176.  Surgical management:
These procedures direct the salivary flow into the mouth or
Depresses the salivary secretion
1. Creating a tract intraorally
2. Duct ligation
3. Sectioning of auriculotemporal nerve
4. Surgical excision of fistulous tract

177. Parotid fistula from transparotid approach for mandibular subcondylar
fracture reduction S. M. Balaji

178. J Oral Maxillolac Surg49:680-682. 1991
Named after Dr. Lucia Frey
• Frey’s syndrome or gustatory sweating and flushing is characterized
by sweating and flushing of the facial skin during meals.
• The area involved is on the lateral aspect of the face and upper neck,
usually around the parotid region.

179. Minor starch iodine test
 The distribution of the greater auricular nerve and ATN was painted with a
solution containing 3 g iodine, 20 g castor oil, and 200 mL of absolute alcohol.
 When dry,the area was lightly dusted with cornstarch.
 Given lemon drops to chew for 4 minutes to induce a salivary response.
 A positive test occurs when sweat dissolves the starch powder and it reacts with the
iodine to produce dark blue spots that may become confluent.

180. (A) Gustatory sweating observed
over the left preauricular region.
(B) A positive Minor’s test over
the left preauricular region

181.  Techniques to evaluate - Blotting paper method
Iodine sublimated paper Histogram
Treatment:
1. external radiotherapy
2. local or systemic application of anticholinergic drugs
Laage-Hellman was the first to apply scopolamine (3%
cream) for the treatment of gustatory sweating.
1. interposition of a subcutaneous barrier
2. injection of botulinum toxin in the involved skin

182. Section of some portion of the efferent neural arc-
Hemenway [62] in 1960 suggested interrupting the efferent
neuronal pathway at the level of the middle ear, by sectioning the tympanic
nerve of Jacobson.
The first such procedure for gustatory sweating was carried out by
Golding-Wood, who named it “tympanic neurectomy"

183.  Surgical Interposition
the use of a barrier between the facial skin and the parotid bed.
 Botulinum Toxin
The injection of botulinum A toxin in the skin involved by gustatory
sweating was recently proposed by Drobik and Laskawi. It acts by blocking
the exocytosis mechanism of the presynaptic terminal, thereby inhibiting
release of acetylcholine.

184. Both the macroscopic and microscopic structures of the TMJ joint are
intimately related with the overall functions of the joint.
Our understanding of the biochemical properties and the structure-function
relationships of the TMJ tissue components can help illuminate pathophysiology
of TMJ disorders, aid in clinical diagnosis and treatments, and inform the design
and development of replacement tissues.

185.  GREY`S ANATOMY (40TH EDITION)
 SICHER & DUBRUL`S ORALANATOMY (8TH EDITION)
 SURGICALAPPROACHES TO FACIAL SKELETON BY EDWARD
ELLIS III
 ANATOMY OF HEAD & NECK BY B.D CHAURSIA
 TEXTOOK OF ORAL & MAXILLOFACIAL SURGERY BY
NEELIMA MALIK
 MANAGEMENT OF TMJ DISORDERS AND OCCLUSION BY
JEFFREY P. OKESON