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Учебники / Color atlas of temporomandibular joint surgery Quinn

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C O N T E N T S

1

Surgical Decision Making for Temporomandibular

 

 

Joint Surgery, 1

 

 

 

2

Diagnostic Imaging

of the

Temporomandibular Joint,

4

3

Surgical Approaches

to the

Temporomandibular Joint,

30

4

Surgery for Internal

Derangements, 55

 

5

Osseous Surgery of the Temporomandibular Joint, 100

6Trauma, 125

7Autogenous and Alloplastic Reconstruction of the Temporomandibular Joint, 170

8Pathology of the Temporomandibular Joint, 213

S U R G I C A L D E C I S I O N M A K I N G IN

T E M P O R O M A N D I B U L A R S U R G E R Y

C H A P T E R O N E

" Who shall decide when doctors disagree?»

ALEXANDER POPE IN " O F THE USE or RICHES"

learly, one of the most vexing problems for oral and maxillofacial surgeons has been selecting the proper surgical option for those patients who have exhausted all conservative methods of dealing with temporomandibular joint pain and dysfunction. Well-reasoned controversy can complicate decision making in temporomandibular joint surgery for internal derangement, trauma, and management of benign and malignant disorders. Several excellent comprehensive textbooks on temporomandibular joint disorders explore the basis for these controversies and provide a historical and scientific overview of this problematic area of

maxillofacial surgery.

The intent of this text is simply to illustrate the technical aspects of the various surgical procedures on the temporomandibular joint. No attempt was made to champion a single approach to temporomandibular joint surgery. Ultimately, only well-designed clinical studies can prove or disprove the safety and efficacy of the individual procedures. It is our hope scientific evidence will one day provide the sine qua non that will dictate the proper role for all the potential surgical modalities, including arthroscopy, meniscal repair, and the use of both autogenous and alloplastic materials in joint reconstruction. Although serious mistakes have been made in the management of the temporomandibular joint, surgeons cannot allow the sins of the past to obscure the needs of the future.

This text is based on the assumption that primarily extraarticular conditions are most amenable to nonsurgical care. Patients with true internal derangements may benefit from nonsurgical care, and all these modalities should be exhausted before proceeding with any surgical option. The following algorithms are useful as guidelines but must always be modified according to the needs of the individual patient. Because several excellent comprehensive texts dealing with arthroscopic techniques are available, this book deals only with open joint surgical procedures.

1

2

Color Atlas of Temporomandibular joint Surgery

Chapter One

Surgical Decision Making in Temporomandibular Surgery

3

C H A P T E R T W O

D I A G N O S T I C I M A G I N G OF

T H E T E M P O R O M A N D I B U L A R J O I N T

Because of the anatomic complexity of the temporomandibular joint and its proximity to the temporal bone, mastoid air cells, and auditory structures,

imaging of the joint structures can be problematic.

PLAIN FILM, TOMOGRAMS, AND PANORAMIC RADIOGRAPHY

Initial screening for gross osseous abnormalities can be performed with standard transcranial (lateral oblique) views. The x-ray beam is angled superiorly to project the joint away from the base of the skull. The transcranial perspective provides a global view of gross bony architecture of the articular surfaces. If possible, a submental vertex film can be taken to allow the lateral oblique transcranial projection to be angled directly through the long access of the condyle. This improves the image quality and also allows standardization of subsequent transcranial views.

Tomography has been widely available since the early 1940s and provides finer detail for the examination of osseous abnormalities than that detected by plain film techniques. The angle-corrected tomograms for sagittal tomography are recommended so that the sectioning is always perpendicular to the long axis of the condyle. This gives a truer picture of the condylar position and allows subsequent comparative studies to be performed by use of a standard method. The angle can be determined by measuring the angle between the condylar axis and a horizontal baseline on a submental vertex view.

Panoramic radiographs have been described as "curved tomograms." They are, in fact, laminograms of a single plane that are adequate for gross screening but limited because of inherent problems with distortion, "ghost" images, magnification (approximately 2 0 % ) , and a loss of sharpness compared with multiplecut, angle-corrected, condylar tomograms.

Newer units allow for separate positioning of right and left joints, creating more correct placement of the condyle in the zone of focus.

Plain films and tomographic images are a great benefit in assessing osseous changes in the condyle and eminence. However, the use of these films to assess condylar position with any accuracy is questionable at best. Several studies have shown that the position of the condyle, as depicted in these radiographic techniques, is of little clinical significance. Openand closed-mouth tomographic views can provide valuable information with regard to condylar translation. Although

4

Chapter Two

Diagnostic Imaging of the Temporomandibular joint

5

A

B

Transcranial radiograph to image contralateral temporomandibular joint. A, Correct positioning. B, Radiographic image.

FIG. 2.1

conventional textbooks have claimed that during normal range of motion the greatest convexity of the condyle reaches the greatest convexity of the articular eminence, several studies have shown that a majority of patients actually can translate beyond the greatest convexity of the articular eminence without subluxation, dislocation, or any symptoms. These studies can diagnose restricted range of motion bur do not provide enough information to determine the etiology of that restriction.

Text continued on p. II

6

Color Atlas of Temporomandibular Joint Surgery

FIG. 2.2

A

B

C

Regular tomography

Corrected tomography

A, Positioning for submental vertex film to determine angulation of condylar head for angle-corrected tomograms. B, Submental vertex view of skull with measurements for angle-corrected tomogram technique. C, Example of 35-degree correction to ensure that tomograms are perpendicular to line drawn from the medial to lateral pole of the condyle.

Chapter Two

Diagnostic Imaging of the Temporomandibular joint

7

FIG. 2.3

A B

A, Patient positioned for angle-corrected temporomandibular joint tomograms. B, Angl&corrected tomogram of right temporomandibular joint.

FIG. 2.4

Representation of sagittal cuts in standard tomographic condylar films, showing representative anatomy from the most lateral to the most medial cut.

8

Color Alias of Temporomandibular Join! Surgery

FIGS. 2.5, 2 . 6

 

Severe

Tomographic technique —Basic principle of tomographic x-rays. Both

Expected contours of lateral condylar tomograms in varying stages

the radiation source and film are moving simultaneously to blur all

of degenerative joint disease,

the anatomy anterior and posterior to the point of plane conver-

 

gence.