approaches to TMJ

1. PRESENTATION BY:
ADITI RAJVANSHI
7-Mar-17
1

2. Introduction
Associated surgical anatomy
Various surgical approaches and their modifications
Complications
References
7-Mar-17 2

3. Temporomandibular joint and its components frequently
require exposure for a myriad of procedures.
7-Mar-17 3

4.  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
7-Mar-17 4

5. 7-Mar-17 5

6. 7-Mar-17 6

7. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed

8. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed

9. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed

10. 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.
7-Mar-17 10

11. A straight trajectory A curved trajectory.
Temporal branches of Facial nerve
Ishikawa Y: An anatomical study on the distribution of the temporal branch of the facial
nerve.
7-Mar-17 11

12. Pitanguy, L, A. S. Ramos: The
frontal branch of the facial
nerve: The importance of its
variation in face lifting.
Plast. Reconstr. Surg. 38 (1966)
352
Middelton’s line
7-Mar-17 12

13. 7-Mar-17 13
The new guideline for preservation of
the entire temporal branch is drawn
with a dashed line.
J.CRANIO-MAX-

14. J.CRANIO-MAX-
FAC.SURG.18(1990),287-292.
7-Mar-17 14

15. Dingman and Grab
Ziarah and Atkinson
7-Mar-17 15

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

17. 7-Mar-17 17
Superficial temporal artery
Transverse facial artery
Maxillary artery
Atlas of human anatomy – Frank H Netter 6th ed

18. 7-Mar-17 18
Auriculotemporal
nerve
Auriculotemporal
nerve
Arises from posterior part of mandibular
division of CN V
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
Atlas of human anatomy – Frank H Netter 6th ed

19. 7-Mar-17 19
Retromandibular vein
Anterior division
Posterior division
Maxillary vein
Superficial temporal vein
GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed

20. 7-Mar-17 20
Greater auricular nerve
largest ascending branch of the cervical plexus
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

21. 7-Mar-17 21

22. Extraoral approaches
1. Preauricular
2. Endaural
3. Postauricular
4. Coronal
5. Retromandibular
6. Submandibular
7. Rhytidectomy
Intraoral approaches
1. Intraoral vestibular –
without endoscope
with endoscope
7-Mar-17 22

23. 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.
7-Mar-17 23

24. 7-Mar-17 24
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

25. 7-Mar-17 25
Incision is outlined at the junction of
facial skin and helix of the ear.

26. 7-Mar-17 26
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Dissection

27. - Rowe NL: Surgery of the temporo-mandibular Joint. Proc R Soc
Med 65:383, 1972
- Al-Kayat A, Bramley P: A modified pre-auricular approach to the
temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979
Suprafascial procedure
Subfascial procedure
Deep Subfascial Approach
- Massimo Politi : J Oral Maxillofac Surg 62:1097-1102, 2004
7-Mar-17 27

28. Politi et al. Deep Subfascial Approach to the TMJ. J Oral Maxillofac
Surg 2004
7-Mar-17 28

29. Incising temporalis fascia
Make an oblique incision parallel to the frontal branch of the facial nerve,
through the superficial layer of the temporalis fascia above the zygomatic arch.
Begins at the root of zygomatic arch and extends anterosuperiorly towards
upper corner of reflected flap
7-Mar-17 29
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

30. Coronal view of dissection to the lateral
portion of the zygomatic arch and
mandibular condyle region.
Insert the periosteal elevator beneath the
superficial layer of the temporalis fascia
and strip the periosteum off the lateral
zygomatic arch.
7-Mar-17 30

31. 7-Mar-17 31
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

32. 7-Mar-17 32
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Blunt dissection below the
zygomatic arch
Exposed TMJ capsule

33. 7-Mar-17 33
First incision is through the
upper joint space
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

34. 7-Mar-17 34
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

35. 7-Mar-17 35
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

36. 7-Mar-17 36
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

37. 7-Mar-17 37

38. Blair’s Inverted Hockey
Stick
Dingman’s Incision Endaural Incision
Popowich and Crane Incision Thoma’s Angulated Incision
7-Mar-17 38

39. 7-Mar-17 39
Skin incision is question mark shaped
Begins antero-superiorly within the
hairline & curves backwards and
downwards well posterior until it meets
upper ear attachment
Incision then follows ear attachment
endauraly
A modified pre-auricular approach to the temporomandibular joint and malar arch
British Journal of Oral Surgery 17 (1979-80), 91-103

40. 7-Mar-17 40
A modified pre-auricular approach to the temporomandibular joint and malar arch
British Journal of Oral Surgery 17 (1979-80), 91-103

41. 7-Mar-17 41
Advantage:
less bleeding
fascial planes can be easily
identified
excellent visibility
good cosmetic result

42.  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
7-Mar-17 42

43. ANATOM
Y
OF
EAR
7-Mar-17 43

44. 7-Mar-17 44
First described by Lempart as an
approach to mastoid process for
surgical improvement of
otosclerosis for approaching TMJ
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

45. 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.
7-Mar-17 45

46. 7-Mar-17 46

47. 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
Disadvantage:
• Esthetic compromise if tragal projection is lost
• Risk of possible perichondritis
7-Mar-17 47

48. 7-Mar-17 48
ADVANTAGES:
• Broad based flap with excellent
blood supply
• Possibility of residual cartilaginous
deformity is less
• Damage to CN VII is unlikely

49. 7-Mar-17 49

50. 7-Mar-17 50

51. 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
7-Mar-17 51
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

52. 7-Mar-17 52
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

53. Transected auditory canal closure of auditory canal
Final closure of the incision. 7-Mar-17 53

54. 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
7-Mar-17 54

55. versatile surgical approach to the upper and middle regions of the
facial skeleton, including the zygomatic arch and TMJ.
major advantage of this approach is that most of the surgical scar
is hidden within the hairline.
7-Mar-17 55

56. 7-Mar-17 56Surgical approaches to facial skeleton – Edward Ellis 2nd ed

57. 7-Mar-17 57
LAYERS OF THE
SCALP
BELOW THE
SUPERIOR
TEMPORAL LINE
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

58. 7-Mar-17 58
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
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

59. 7-Mar-17 59
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

60. The incision is through the skin, subcutaneous tissue, and
galea revealing the subgaleal plane of loose areolar
connective tissue overlying the pericranium
7-Mar-17 60
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

61. 7-Mar-17 61Surgical approaches to facial skeleton – Edward Ellis 2nd ed

62. 7-Mar-17 62
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.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

63. 7-Mar-17 63
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
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

64. 7-Mar-17 64
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
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

65. 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.
7-Mar-17 65

66. 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.
7-Mar-17 66

67. 7-Mar-17 67
The coronal incision has been modified.
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.
AD: further camouflage of the scar

68. 7-Mar-17 68

69. 7-Mar-17 69
Incision usually starts 1.5-2cm inferior to the lower border of mandible.
The initial incision is carried through the skin and subcutaneous tissues to
the level of the platysma muscle.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

70. 7-Mar-17 70
Dissection of platysma and exposure of
superficial layer of deep cervical fascia
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

71. dissection to the pterygomasseteric muscular sling
7-Mar-17 71Surgical approaches to facial skeleton – Edward Ellis 2nd ed

72. 7-Mar-17 72
Associated anatomic structures
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

73. 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
7-Mar-17 73

74. 7-Mar-17 74
With retraction of the dissected
tissues, the inferior border of
the mandible is seen.
The pterygomasseteric sling is
sharply incised with a scalpel
along the inferior border
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

75. 7-Mar-17 75
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

76. the masseter and medial pterygoid
muscles are sutured together
subcutaneous tissues and skin
closure is done
7-Mar-17 76
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

77. 7-Mar-17 77

78. exposes the entire ramus
from behind the posterior
border.
therefore may be useful for
procedures involving the area
on or near the Condylar
neck/head, or the ramus itself7-Mar-17 78
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

79. 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.
7-Mar-17 79

80. 7-Mar-17 80
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

81. 7-Mar-17 81Surgical approaches to facial skeleton – Edward Ellis 2nd ed

82. 7-Mar-17 82
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

83. 7-Mar-17 83
Blunt dissection
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

84. 7-Mar-17 84 Surgical approaches to facial skeleton – Edward Ellis 2nd ed

85. 7-Mar-17 85Surgical approaches to facial skeleton – Edward Ellis 2nd ed

86. 7-Mar-17 86
Approximating pterygomasseteric sling
Closure of parotid capsule
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

87. J ORAL MAXILLOFAC SURG 67:2418-2424, 2009
7-Mar-17 87

88. 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.
7-Mar-17 88

89. 7-Mar-17 89

90.  Also called as facelift approach.
Variant of retromandibular, transmasseteric -
anteroparotid approach
7-Mar-17 92

91. 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
7-Mar-17 93

92. 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.
7-Mar-17 94
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

93. 7-Mar-17 95
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

94. 7-Mar-17 96
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

95. 7-Mar-17 97
Surgical approaches to facial skeleton – Edward Ellis 2nd ed

96. 7-Mar-17 98Surgical approaches to facial skeleton – Edward Ellis 2nd ed

97. 7-Mar-17 99

98. 7-Mar-17 100
Gap arthroplasty for temporomandibular joint ankyloses by transoral approach: A case series
Int. J. Oral Maxillofac Surg

99. 7-Mar-17 101
AD:
• better visibility
• access to high level fracture
using transbuccal trocar.

100. 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.
7-Mar-17 102

101. ;
7-Mar-17 103
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.
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

102. 7-Mar-17 104
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
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

103. 7-Mar-17 105
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.
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

104. 7-Mar-17 106
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

105. 7-Mar-17 107
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed

106. 1. Poor facial scar
2. Infection
3. Wound dehiscence
4. Facial nerve palsy
5. Perichondritis
6. Sialocoele
7. Frey’s syndrome
7-Mar-17 108

107. 7-Mar-17 109

108. 7-Mar-17 110

109. 7-Mar-17 111
SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration

110. 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.
7-Mar-17 112

111. 7-Mar-17 113
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.

112. MANAGEMENT
1. Small sialocoeles have said to resolve spontaneously by scar
formation which seals the salivary flow.
1. Non surgical management:
 repeated aspirations and compression dressings
 administration of anticholinergics
 antisialogogues
7-Mar-17 114

113. 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
7-Mar-17 115

114. 7-Mar-17 116
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.

115. 7-Mar-17 117
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

116. 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
7-Mar-17 118

117. 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
7-Mar-17 119

118. 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.
7-Mar-17 120

119. Know your anatomy properly.
- Emphasis on Facial .N relation to
fascial layers.
Importance of maintaining proper
dissection plane.
Chose the appropriate approach based
on the problem.
Be aware of the possible complications
from each of the approach.

120. 1. GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
2. Atlas of human anatomy – Frank H Netter 6th ed
3. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
4. Oral and maxillofacial trauma – Fonseca 4th ed
5. Surgical approaches to facial skeleton – Edward Ellis 2nd ed
6. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
7. Salivary gland disorders - Myers
8. An Anatomical Study on the Distribution of the Temporal Branch of the
Facial Nerve - J. Cranio-Max.-Fac. Surg. 18 (1990) 287-292.
9. A modified pre-auricular approach to the temporomandibular joint and
malar arch - British Journal of Oral Surgery 17 (1979-80), 91-103.
10. The surgical anatomy of the mandibular distribution of the facial nerve
British Journal of Oral Surgery (1981) 19, 159-l 70. 7-Mar-17 122

121.  A Modified Endaural Approach to the Temporomandibular JointOral Maxillofac
Surge 51:33-37,1993.
 A new modified endaural approach for access to the temporomandibular joint
British Journal of Oral and Maxillofacial Surgery (2001) 39, 371–373.
 The Deep Subfascial Approach to the Temporomandibular Joint - J Oral
Maxillofac Surg 62:1097-1102, 2004.
 Ankylosis of temporomandibular joint - Dingman
 A truly endaural approach to the temporo-mandibular joint - British Journal of
Plastic Surgery (1984) 37,65-68.
 Transmasseter Approach to Condylar Fractures by Mini-Retromandibular Access
- J Oral Maxillofac Surg 67:2418-2424, 2009
 Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular
Condyle Fracture of the Mandible - J Oral Maxillofac Surg 68:1578-1584, 2010.
 The post-auricular approach for gap arthroplasty e A clinical investigation -
Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500-505.
7-Mar-17 123