Учебники / Color atlas of temporomandibular joint surgery Quinn
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Chapter Five |
Osseous Surgery of the Temporomandibular joint |
1 13 |
FIG. 5. 17
Condylectomy is performed through the standard endaural approach used to identify the neck of the condyle at the level of the sigmoid notch below the most inferior-lateral capsular attachment. The condyle is sectioned while protection is provided to the interior maxillary artery, which lies medial to the condylar neck. In the high condylectomy, 7- to 8-mm of the entire condylar head is removed for intractable temporomandibular joint pain that is unresponsive to conservative therapy. This differs from condylectomy performed for prosthetic joint placement or costochondral rib grafting, in which the osteotomy cut is at the base of the coronoid to prevent postsurgical ankylosis.
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Color Atlas of Temporomandibular Joint Surgery |
FIG. 5 . 18
Three-dimensional CT scan showing the shape of the condylar neck at the level of the coronoid notch.
Osseous Surgery of the Temporomandibular Joint |
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FIG. 5 . 19
A
B
A coronal CT scan bone window showing fibroosseous ankylosis of the right condyle. Note the complete fne absence ot any identifiable joint space.
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Color Atlas of Temporomandibular Joint Surgery |
FIG. 5.20
A B
c
A, B, Dunn-Dautrey retractors in place for condylectomy, C, A 1-mm fissure bur is used to make the
osteotomy cut at the neck of the condyle. Dunn-Dautrey retractors protect the internal maxillary artery dur-
ing the procedure. |
Continued |
Chapter Five |
Osseous Surgery of the Temporomandibular Joint |
1 17 |
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FIG. 5.20, CONT'D
D
E
D, Small T-bar osteotome is gently lapped to separate the thin medial cortex of the condyle E, The T-bar osteotome is rotated 180 degrees to mobilize the condylar head. A sharp periosteal elevator is then used to strip the lateral pterygoid attachment: rom the anterior surface of the condyle.
1 1 8 |
Color Atlas of Temporomandibular Joint Surgery |
FIG. 5.21
A B
A, Bony ankylosis of right temporomandibular joint. B, Note position of Dunn-Daulrey condylar retractors behind the neck of the condyle to protect the internal maxillary artery during condylar osteotomy.
FIG. 5-22
A B
A, Open arthroplasty view of bony ankylosis of the left temporomandibular joint. B, Note that the osteotomy cut has been purposely placed inferior to suspected position of the joint space to prevent inadvertent
perforation into the middle cranial fossa. Continued
Chapter Fife |
Osseous Surgery of the Temporomandibular Joint |
1 1 9 |
FIG. 5.22, CONT'D
c
C, Diagram of the procedure.
FIG. 5.23
Use of spring-loaded Bell exerciser to lyse adhesions status postcondylectomy.
1 2 0
FIG. 5.24
Color Atlas of Temporomandibular Joint Surgery
CONDYLOTOMY
Condylotomy for chronic temporomandibular joint pain was popularized by Ward in 1952. Performed with a Gigli saw, the procedure was designed to induce a displaced fracture through the condylar neck so that the condyle would be repositioned inferiorly and anteriorly. This would allow the condylar head to seat under rhe displaced meniscus and unload the posterior attachment.
Nickerson, Hall, and others have renewed interest in the concept of this procedure, and they have popularized an open approach to the condylotomy. An intraoral, subsigmoid, vertical osteotomy is performed, and the patient is maintained in intermaxillary fixation with elastics for a 2- to 4-week period.
A
A, Ward condylotomy. Note the telescoping of the condylar segment in an anterior and inferior position. This malpositioned condyle would theoretically unload the meniscus and result in c more physiologic
condyle-disk relationship. Continued
Chapter Five |
Osseous Surgery of the Temporomandibular joint |
121 |
FIG. 5.24, CONT'D
B, Ward condylolomy. Coslich needle is passed posterior to the ramus with the exit point in the coronoid notch. Great care is taken to ensure the needle is passed in close proximity to the lateral surface of the condylar neck to avoid entrapping the internal maxillary artery between the Gigli saw and the condylar neck. C, Carefully sectioning the condylar neck at the level of the sigmoid notch, the operator does not bring the Gigli saw completely through all the cortical bone and periosteum on the lateral side but rather leaves a small bridge of bone and soft tissue that can be fractured with digital pressure. This prevents a complete dislocation of the segment ou; of the glenoid fossa by the unopposed lateral pterygoid muscle. Similar to the intraoral vertical subsigmoid osteotomy, this procedure theoretically induces an anteriorinferior displacement of the condylar head, thereby allowing the osteotomized condyle to seek a better
position in relation to the displaced meniscus Continued
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Color Atlas of Temporomandibular joint Surgery |
FIG. 5.24, CONT'D
D E
D, Outline of the right condyle ramus complex on the skin, showing insertion of Costich needle with entry mark on the posterior border of mandible. This technique was designed to bring the sharp tip of the Costich needle directly behind the neck of the condyle and cause the lip of the needle to exit through the coronoid notch. Care must be taken during this maneuver to remain lateral to the internal maxillary artery.
E, Costich needle exiting through the coronoid notch with Gigli saw attached to the perforation in the terminal lip of the Costich needle. The Gigli saw is ihen pulled back through the coronoid incision so thai its culling surface lies along the medial surface of the condylar neck.