Surgical approaches of TMJ /certified fixed orthodontic courses by Indian dental academy

SURGICAL ANATOMY OF THE
TEMPOROMANDIBULAR JOINT AND
SURGICAL APPROACHES

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION
The TMJ and its components frequently require
exposure for a myriad of procedures.
Internal derangements of the TMJ, arthritis, trauma,
developmental disorders, and neoplasia may all affect
the TMJ and/or the skeletal and the soft tissue
components.

Several approaches to the TMJ have been proposed and
used clinically.
Pre auricular
Modifications – Blair’s

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Thoma’s
Al – kayat and Bramleys
Popowich’s modification of Al – kayat and Bramleys
Endaural approach
Post auricular approach
Submandibular (Risdon’s ) approach
Post ramal ( Hind’s ) approach
Hemicoronal approach
Coronal or bicoronal approach

The selected approach should accomplish the following:
Maximize exposure for the specific procedure
Avoid damage to the branches of the facial nerve
Avoid damage to major vessels
Avoid damage to the parotid gland
Maximize use of natural skin creases for cosmetic wound
closure

PRE AURICULAR APPROACH
The pre auricular incisions
used today are essentially
modifications of Blair
curvilinear or inverted L
incision.


FACIAL NERVE
The main trunk of the facial nerve exits from the skull at
the stylomastoid foramen.
Approximately 1.3 cm of the nerve is visible before it
divides into temporofacial and cervicofacial branches.


FACIAL NERVE
During surgery by incising the superficial layer of the temporalis
fascia and the periosteum over the arch inside the 8 mm boundary,
damage to the branches of the upper trunk can be prevented.


FACIAL NERVE
The temporal branch of the facial nerve innervates the
frontalis, the corrugator, the procerus and occasionally a
portion of he orbicularis oculi muscle.
Post surgical palsy manifests as an inability to raise the
eyebrow or wrinkle the forehead and ptosis of the brow.
Damage to the zygomatic branch results in temporary or
permanent paresis to the orbicularis oculi.


AURICULOTEMPORAL NERVE
The auriculotemporal nerve
supplies sensation to parts of
the auricle, the external
auditory meatus, the tympanic
membrane, and skin in the
temporal area.
Damage to this nerve can be
prevented during surgery by
incising and dissecting in close
apposition to the cartilaginous
portion of the external auditory
meatus


Marking the incision.
Infiltration of vasoconstrictor.
If LA is also used it should not
be injected deeply .. nerve
stimulator


Incision thru skin sc tissues
including the temporoparietal
fascia till the superficial layer of
temporalis fascia.


Blunt dissection to
undermine superior part
of incision ( above ZA ).
Flap dissected at the
level of outer layer of
temporalis fascia.
Below the ZA blunt
dissection adjacent to the
EAC followed by scissor
dissection.


Incision through the superficial
(outer) layer of temporalis
fascia beginning from the root
of the ZA just in front of the
tragus anterosuperiorly toward
the upper corner of the
retracted flap.
The fat globules contained
between the layers of TF are
exposed.
At the root of the zygoma
incision is thru superficial layer
fo temporalis fascia and
periosteum of the ZA.

Blunt dissection with
periosteal elevator deep
to superficial layer of
temporalis fascia to
dissect it from underlying
areolar and adipose
tissue.
Cleave the attachment of
the periosteum at the
junction of lat. and sup.
surfaces of the ZA.

Continue blunt dissection inferiorly, taking care not to
dissect medially into the TMJ capsule.


As the dissection proceeds
approximately 1 cm below
the ZA the intervening
tissue is released along the
plane of the initial incision.


Distracting the condyle
inferiorly, pointed scissors
are used to enter the upper
joint space anteriorly along
the posterior slope of the
eminence.
This opening is extended
anteroposteriorly by cutting
along the lateral aspect of
the eminence and the
fossa.


The inferior joint space is
opened by making an
incision in the disk along
its lateral attachment to
the condyle within the
lateral recess of the
upper joint space.


MODIFICATIONS OF THE PRE
AURICULAR INCISION
Al Kayat and Bramley
modification of the pre
auricular incision.
The temporal incision is
carried thru the skin,
superficial fascia to the level
of the temporalis fascia.
Facial n. brs. run in the
superficial fascia, so full
length of the fascia should be
reflected with the skin flap.


Blunt dissection carried
out till about 2 cms
above the ZA where
the temporalis fascia
splits.
Starting at the root of
the ZA an incision is
made…..
Downward dissection
will expose the capsule
and then the dissection
is carried out as usual.

ADVANTAGES
Reduction in the incidence of facial nerve palsy.
Provision of donor site for temporalis fascia.
Decreased haemorrhage (disseciton thru avascular plane)
Improved visibility and identification of fascial planes.
Reduction in post op edema and discomfort.
Potential complications of muscle herniation and fibrosis
are avoided.
Good cosmetic result.
Reduction of total operating time.


MODIFICATIONS OF THE PRE
AURICULAR INCISION


ENDAURAL APPROACH
The endaural incision is simply
a cosmetic modification of the
pre auricular incision.
It moves the skin incision from
the pretragal crease posteriorly
so that the incision is placed
on the prominence of the
tragus itself.
In the superior portion the
incision is deepened to the
level of the temporalis fascia.
Inferiorly sharp dissection is
carried out for some distance
along the perichondrium.


SUBMANDIBULAR APPROACH
SURGICAL ANATOMY
Marginal mandibular Br. of the
facial nerve
Dingman and Grabb – dissection
of 100 facial halves.
They found marginal mandibular
was upto I cm below the inferior
border of the mandible in 19%
cases
Anterior to the point where the
nerve crossed the facial artery
the nerve was above the inferior
border in all the cases.

21 % of the cases had a single
marginal mandibular branch.
67 % had 2 branches.
9 % had 3 branches
3 % had 4 branches.


ZARIAH and ATKINSON
In 53% OF 76 facial halves the
marginal mandibular branch was
below the lower border of the
mandible before reaching the
facial vessels.
In 6 % of the cases the nerve
continued further upto 1.5 cm
before turning upward to cross
the mandible.
The farthest distance from the
inferior border of the mandible
was 1.2 cm.
In view of these findings the
incision and deeper dissection
should be at least 1.5 cm below
the inferior border

Facial artery
The facial artery appears on
the external surface of the
mandible around the anterior
border of the masseter muscle.
Facial vein
The facial vein generally
courses with the facial artery
above the level of the of the
inferior mandibular border but
it is posterior to the artery.


Marking the incision
The incision is 1.5 – 2 cm
inferior to the mandible.
Infiltration of
vasoconstrictor with local
anesthetic should not be
deep to the platysma
muscle – marginal
mandibular br.


The initial incision is
carried through the skin
and sc tissue to the level
of the platysma muscle.
The skin is undermined
with scissor dissection in
all directions to facilitate
closure.


Division of the fibers of
the platysma can be done
sharply or in a more
controlled method


Dissection thru the superficial
layer of deep cervical fascia
Care should be taken to avoid
damage to the marginal
mandibular nerve.
The facial vessels can be
retracted or clamped, divided and
ligated as required.


Dissection continues until
the only remaining tissue
on the inferior border of
the mandible is
periosteum (ant. to the
premasseteric notch) or
the pterygomasseteric
sling.


The pterygomasseteric
sling is sharply incised
with a scalpel along the
inferior border.
This is the most
avascular portion of the
sling.


Strip the masseter.


POST RAMAL (HIND’S) APPROACH
SURGICAL ANATOMY
Facial nerve
Retromandibular vein


Skin marking
Infiltration of
vasoconstrictor.
The incision begins 0.5 cm
below the lobe of the ear
and is about 3 – 3.5 cm
long.
The initial skin incision is
carried thru the skin, sc
tissue to the level of the
platysma.
Skin undermining..

The platysma muscle is sharply
incised in the same plane as the
skin incision.
Then the superficial
musculoaponeurotic layer and
parotid capsule are incised and
blunt dissection begun within the
gland in anteromedial direction
toward posterior border of the
mandible.

Hemostat is inserted parallel to
the anticipated direction of
branches of the facial nerve.
The dissection continues until
the only tissue remaining on
the posterior border of the
mandible is the periosteum of
the pterygomasseteric sling.


Retraction of the
tissues is done.
The
pterygomasseteric
sling is sharply
incised with a scalpel.


Strip the masseter.
Clean dissection is facilitated by
stripping the muscle from top to
bottom.


POST AURICULAR APPROACH
The incision begins near the
superior aspect of the
external pinna and is
extended to the tip of the
mastoid process.
The incision is made 3 – 5
mm parallel and posterior to
the post auricular flexure.
The incision is carried
sharply down thru the
postauricular muscle to the
mastoid fascia and the
temporalis fascia superiorly.

A combination of blunt and
sharp dissection is used to
isolate the cartilaginous portion
of the external auditory canal.
A blunt instrument is placed in
the EA canal to assist in the
transection of the EA canal.
The incision should leave 3 – 4
mm of cartilage on the medial
aspect to permit adequate
approximation of the canal.

The incision is carried
thru the outer layer of the
temporalis fascia,
continuing inferiorly,
reflecting the
parotidomasseteric fascia
off the ZA and the lateral
TMJ ligament.

HEMICORONAL AND BICORONAL
INCISIONS
These are more extensive, but versatile surgical
approach to the upper and middle regions of the facial
skeleton, including zygomatic arch and the TMJ areas.
The major advantage of this approach is that most of the
scar is hidden within the hairline when the incisions are
extended into the preauricular region, the surgical scar is
inconspicuous.
The incision can be utilized for more extensive bilateral
involvement.

REFERENCES
COLOR ATLAS OF TMJ SURGERY – PETER D. QUINN
FONSECA ORAL AND MAXILLOFACIAL SURGERY VOL. 4 –
BAYS and QUINN
THE TMJ AND RELATED OROFACIAL DISORDERS – BUSH and
DOLWICK
SURGICAL APPROACHES TO THE FACIAL SKELETON –
EDWARD ELLIS
SURGERY OF THE TMJ. SURGICAL ANATOMY AND SURGICAL
INCISIONS – KREUTZIGER (ORAL SURGERY. 58; 637-646, 1984)
A MODIFIED PRE AURICULAR APPROACH TO THE TMJ AND
MALAR ARCH – ADIL AL KAYAT AND PAUL BRAMLEY (BJOS.

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