Учебники / Color atlas of temporomandibular joint surgery Quinn
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Chapter Four Surgery for Internal Derangements |
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FIG. 4 . 56
A B
A, Temporalis fascia graft harvested for autogenous meniscal replacement by extension of temporal arthroplasty incision. B, Diagram of temporalis fascia as a source of autogenous meniscal replacement tissue.
A
A, B, Status postmeniscectomy with temporalis fascial graft in position. Graft is sutured anteriorly to anterior capsular ligament and the lateral pterygoid muscle and posteriorly to the posterior attachment.
FIG. 4 . 57
B
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Color Atlas of Temporomandibular joint Surgery |
FIG. 4.58
A B
Fresh-frozen femoral head cartilage for meniscal replacement. A, Removing bone from undersurface of cartilage. B, Cartilage after bone removal.
FIG. 4 . 59
Double layer of fresh-frozen femoral head cartilage in glenoid fossa to offset loss of vertical height in condyle secondary to erosion from PTFE-implant giant cell reaction.
Chapter Four Surgery for Internal Derangements |
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A B
A, Interiorly based temporalis flap is elevated, with care taken to maintain blood supply from the superficial temporal artery. B, The edges of the temporalis flap are sutured around its circumference with a running 3-0 chromic stitch. The flap is then rotated down around the lateral portion of the zygomatic arch and into the glenoid fossa as a lining graft after meniscectomy.
FIG. 4 . 60
TEMPORALIS MUSCLE AND FASCIAL GRAFTS
Temporalis fascia was used as a free autogenous interpositional graft in the past but has largely been abandoned in favor of the temporalis myofascial flap because the fascia alone proved insufficient in mass to function adequately. The temporalis myofascial flap is harvested by extending the endaural incision into the temporal region approximately 2 to 3 cm. This interiorly based flap, a full-thickness flap incorporating the muscle with superficial and deep fascia, is outlined and freed with a #15 blade or a cautery tip. To account for contraction, the distal width of the flap should be wider than the actual dimensions of the joint space to be covered. In general, the length of the flap from the superior edge to the zygomatic arch is 5 to 6 cm and approximately 3 cm in width. The edges of the flap are then sewed together with multiple 4-0 chromic sutures. The flap is rotated laterally over the zygomatic arch and placed as a lining into the glenoid fossa so that the periosteum from the temporal bone is facing against the glenoid fossa. The flap is held in position with two nonresorbablc sutures that are passed through holes drilled in the posterior edge of the fossa and the bone on the anterior slope of the eminence.
An alternative method for placing the temporalis flap is to raise the same inferiorly based temporalis myofascial flap, bring the free edge through the infratemporal space, and pass it from the articular eminence posteriorly into the joint space. Once it is passed under the articular eminence, it is sutured to the rim of the glenoid fossa in a similar fashion.
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Color Atlas of Temporomandibular Joint Surgery |
FIG. 4 . 61
Inferiorly based temporalis flap with blood supply from the superficial temporal artery, which is shown being positioned inferiorly and lateral to the zygomatic arch as a lining tissue for the temporomandibular joint after meniscectomy, with or without condyloplasty.
Chapter lour Surgery /or Internal Derangements |
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FIG. 4.62
A
B
c
A through C, Inferiorly based temporalis flap, which is secured into the fossa from an anterior approach to provide lining for the glenoid fossa after meniscectomy.
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FIG. 4.63
Color Atlas of Temporomandibular Joint Surgery
Postoperative care is clearly an important aspect of any intracapsular joint surgery. Aggressive and early mobilization of the joint is tantamount to success. In most patients, regardless of the type of surgical procedure, progressive mobilization, with active motion exercises, is adequate to achieve an interincisal opening of approximately 35 mm within 4 to 6 weeks of surgery. Hand-held jaw-exercise devices are available to assist patients in achieving this goal. In patients who have had multiple operations or continued problems with adhesions or heterotopic bone
formation, a continuous passive motion device, in conjunction with active physiotherapy, can be helpful. In general, mobilization without mastication-induced joint loading should be encouraged for the first few weeks after surgery. A soft diet is usually advocated in the first 4 to 6 weeks following surgery. Once an adequate, pain-free interincisal opening is achieved, the diet can be rapidly advanced.
Postsurgical patient demonstrating the use of Therabite jaw exerciser. Patients are instructed to use a hand-held jaw mobilization device 3 to 4 times daily for a period of 4 to 6 weeks after surgery to maintain mobility.
Chapter Four Surgery for Internal Derangements |
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FIG. 4 . 64
A B
A, E-Z Flex mandibular exerciser being used by postmeniscectomy patient. B, Close-up view of the E-Z Flex device.
FIG. 4.65
Continuous passive motion apparatus used for rehabilitation after joint surgery.
C H A P T E R FIVE
O S S E O U S S U R G E R Y OF THE
T E M P O R O M A N D I B U L A R
J O I N T
CONDYLOPLASTY
Several authors have popularized the technique of condyloplasty, or condylar shave. Arthroplasty is the reshaping of articular surfaces to remove irregularities (osteophytes) and erosions. It can be performed as an isolated procedure or in conjunction with meniscal repair. It appears to be more suited for small, isolated areas of disease, as opposed to the practice of removing 3 to 4 mm of the entire anterior-superior slope of the condyle. Follow-up of condyloplasty patients shows significant evidence of progressive degeneration with sclerosis and erosion. Fibrocartilage does not regenerate in areas where condyloplasty has been performed.
FIG. 5.1
Bone file being used to contour the head of the condyle during condyloplasty procedure. Although this maneuver can sometimes be beneficial in removing osteophytes, the fibrocartilage damaged during the procedure does not regenerate and further degenerative changes can occur secondary to the procedure itself.
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Chapter Five Osseous Surgery of the Temporomandibular Joint |
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FIG. 5.2
High condylar shave. A I-mm fissure bur is used to remove a 3- to 4-mm section of the anterior-superior slope of the condyle. The cortical edges are then smoothed with a bone file. This maneuver often exposes underlying marrow in the condylar head and leads to progressive sclerosis and degeneration. (This procedure, in widespread use in the 1970s and early 1980s, involved a 2- to 4-mm resection of the anteriorsuperior slope of condyles that exhibited signs of degeneration, including sclerosis, breaking, subchondral cysts, and osteophytes.)
FIGS. 5 . 3, 5 . 4
Condylar shave specimen. Note that the entire surface of the ante- rior-superior slope of the condyle with its fibrocartilage, cortical bone, and a small amount of cancellous bone has been removed.
Cryoseclion showing the dimensions of the anterior-superior condylar head in area where condylar shave is performed,
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FIG. 5.5
Side view of a skull depicting the position of the condyle anterior to the eminence in dislocation.
Dislocation implies complete separation of the articular surfaces of the condyle and articular eminence. Subluxation is partial separation of these surfaces and is self-reducing. In unilateral dislocation, there should be deviation of the midline to the contralateral side with an ipsilateral open bite.
Color Atlas of Temporomandibular Joint Surgery
EMINOPLASTY
Eminoplasty-eminenectomy can be an important adjunct in the surgical correction of internal derangements, or it can be used alone for treatment of hypermobility. Standard texts have defined normal maximal translation of the condyle as the point where the greatest convexity of the condyle meets the greatest convexity of the articular eminence. In practice, as many as 6 0 % of normal subjects translate more anterior than that point without any symptoms. Subluxation occurs when the condyle translates anterior to its normal range and the patient exhibits a temporary locking or sticking sensation that either abates spontaneously or can be reduced with manual self-manipulation. Dislocation is a more advanced hypertranslation where the condyle locks out anterior to the eminence to a position where it cannot be self-reduced. Recurrent dislocation is treated with eminenectomy.
The eminence must be recontoured as far medially as possible to ensure that adequate bone is removed.
Note: Computer tomographic (CT) or magnetic resonance imaging (MRI) images can show the extension of the cancellous bone in the eminence, so care is exercised to prevent intracranial exposure of the temporal lobe.
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