Te c h n o l o g i c a l

Advances in
Minimally Invasive
TMJ Surgery
Joshua Wolf,

a,
DDS *,

Adam Weiss,

DDS

, Harry Dym,

DDS

a,b

KEYWORDS
 TMJ surgery  Arthrocentesis  Arthroscopy
 Temporomandibular joint

The technological advances in temporomandibular arthroscopy and arthrocentesis

have given oral surgeons a treatment for patients who have not responded to conservative and pharmacologic treatment without the surgical risks and long-term recovery
of open joint surgery.
The development of a less-invasive surgical treatment of temporomandibular joint
(TMJ) pathology began in 1975 when Ohnishi first used an arthoscope to enter and
study the TMJ.1 The major surgical procedures that would follow to be used with
the arthroscope were diagnostic, by attaching the arthroscope to a screen to visualize
the joint and the lysis and lavage of the joint (Fig. 1). This procedure most commonly
involves the placement of two arthroscopic portals, one of which is for the arthroscope
and the other for a blunt probe. As the joint is observed and the adhesions are encountered, the probe can be used in a sweeping fashion to break up the adhesion. The use
of the probe along with the hydraulic distention of the joint allow for stretching of the
joint space. Images of preparation for and performing the procedure can be seen in
Fig. 2. When the adhesions are broken down and the joint space distended, the joint
movement improves and range of motion increases. Drugs, such as corticosteroids
and sodium hyaluronate, have also been injected following the joint to reduce inflammation and improve lubrication, respectively. By 1991, Nitzan and colleagues showed
that performing lavage of the TMJ without the scope, a procedure called arthrocentesis, gave similar results in the reduction of pain with success rates in up to 91% of
patients.2 Arthrocentesis involves placement of two cannulas into the superior joint
for hydraulic distension and joint lavage. The initial application of the procedure was

Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb
Avenue, Brooklyn, NY 11201, USA
b
Department of Dentistry, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY
11201, USA
* Corresponding author.
E-mail address: wolfjoshuac@gmail.com
Dent Clin N Am 55 (2011) 635640
doi:10.1016/j.cden.2011.03.001
dental.theclinics.com
0011-8532/11/$ see front matter 2011 Elsevier Inc. All rights reserved.

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Wolf et al

Fig. 1. (A) Drawing of the TMJ. The articular disc positioned between the mandibular
condyle and articular fossa and eminence divide the joint into upper and lower compartments. (B) Arthroscopic view of upper compartment using the Onpoint 1.2 mm Scope
System.

for the treatment of internal derangement of the TMJ. Later stages in this disorder can
eventually lead to anterior disc displacement without reduction, also called closed
lock because of the limited mobility of the jaw. This disorder is often accompanied
by pain but the exact mechanism seems multifaceted. With the procedures success
in reducing pain and increasing mobility, arthrocentesis was expanded for treatment in
other joint disorders. Recent comparisons between arthroscopy and arthrocentesis
have shown both procedures to be successful (82% to 75%, respectively) with no
significant difference in their success rates. Some investigators have argued that
patients with chronic long-standing closed lock are more resistant to arthrocentesis
and require TMJ arthroscopic lysis and lavage.3
There have been many theories as to the etiology of TMJ dysfunction and of how it
results in pain. The focus of TMJ research at one time was on the shape and anatomic
position of the deranged disc but the focus has changed to the biochemical

Fig. 2. (A) Patient is properly draped and local anesthetic is given into planned puncture
point. (B) The upper joint compartment is entered and joint is insufflated with lactated
Ringer solution. (C) Scope is placed into the cannula to perform arthroscopy.

Advances in Minimally Invasive TMJ Surgery

environment and inflammatory mediators related to the pathologic joint. One theory for
the success of arthrocentesis comes from the active elimination of the altered synovial
fluid, which, together with physiotherapy, produces improved joint function with
a diminished pain sensation.4 Despite many studies showing that disc position and
perforations do not improve with arthrocentesis, many patients have experienced
improved TMJ function with less pain from this procedure.5
Before arthroscopic surgery or arthrocentesis is performed, conservative management must be attempted to see if symptoms can be relieved with out surgery. Literature has shown that nonsurgical management, which includes physical therapy,
behavioral changes, and pharmaceuticals for internal derangement, can improve
a patients symptoms without the need for surgical treatment from 74% to 85% of
the time.6,7 Those who do not respond to conservative treatment may still benefit
from arthrocentesis and/or arthroscopic lysis and lavage. Kim and colleagues8 conducted a study investigating closed lock patients who had not shown response to
the conservative treatment for more than 3 months. TMJ lysis and lavage were performed using an ultrathin arthroscopy, and positive outcomes were found in 80% of
patients.
The other major indications for arthrocentesis are9
1. Acute and chronic limitation of opening because of anteriorly displaced disc
without reduction
2. Chronic pain with good range of motion and anterior disc displacement with
reduction
3. Degenerative osteoarthritis
4. A condition of TMJ open lock where the condyle is entrapped anterior to the
condyle.
Contraindications to TMJ arthrocentesis are patients who have undergone successful conservative treatment, demonstrate bony or fibrous ankylosis, or have extracapsular sources of pain.
Arthrocentesis of the TMJ may be performed with the patient receiving a local anesthetic, intravenous conscious sedation, or general anesthetic depending on surgeon
and patient preference.
As TMJ arthroscopy and arthrocentesis have gained popularity, new techniques,
entry portals, and technology have been developed to enhance the classic arthroscopic procedure of the TMJ.
Moses10 highlighted the general principles that all arthroscopy techniques must
include the following:
1. The joint should be fully distended allowing easier trocar puncture and minimizing
the risk of iatrogenic intracapsular damage.
2. The skin should be punctured with a sharp trocar.
3. All intracapsular procedures should be done with care to prevent articular surface
damage.
4. Attention should be given to preserve as much healthy synovium as possible to
enhance its physiologic effects on the joint.
5. The joint space should be kept expanded during instrumentation by a slow infusion
irrigation system.
Over the past two decades the popularity of arthroscopy and arthrocentesis has
grown because it has been considered a safe and effective procedure for TMJ pain
with a low complication rate. Tsuyama and colleagues11 first reported a 10.3%
complication rate after arthroscopic procedures but a larger and more recent study

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showed a complication of only 1.3%, demonstrating the success of the new techniques and surgeons increased experience with arthroscopy.12 The major portion
of complications was otologic problems, including blood clots in the external auditory
meatus, perforation of the tympanic membrane, partial hearing loss, ear fullness, and
vertigo. Other injuries included neurologic injury to fifth and seventh cranial nerves and
TMJ injury possibly causing osteoarthritis. Correct portal placement lowers the chances of complications and decreases the chances of limited access within the TMJ
during the arthroscopic technique. McCain and de la Rua13 are given credit for
combining anatomic knowledge with a surgical perspective, giving detailed, precise
anatomic measurements for portal placement. Due to the anatomic variations from
one patient to another, the portals are anatomically measured, then palpated for
confirmation before cannulization is started.
Some of the major contributions to TMJ arthroscopy have come from the technological advances in arthroscopes. The improvements in camera and lens technology have
advanced the ability to diagnose a wide variety of pathologic conditions within the
TMJ. The Onpoint 1.2 mm Scope System is an innovative breakthrough that provides
minimally invasive visualization of the joint in the convenience of an office-based
setting (Fig. 3). The button on the hand piece allows still image and video recording
for the visual effect of patient instruction, and visualization and smaller size could
prevent complications. The disposable fiberoptic scope tube is approximately the
size of an 18-gauge needle and is sterile packaged for single use. The Onpoint system
is a single-portal system, thereby requiring only one puncture of the joint, and the new
fiberoptic design tolerates more flexion to help avoid tissue trauma.
Advances in TMJ arthroscopy have also benefited from the addition of new laser
surgery techniques. Procedures that can be performed with the holmium:YAG laser
system include anterior muscle release procedures, lysing fibrous adhesions, treatment
of chondromalacia, tissue debridement in symptomatic degenerative joint disease,
treatment of synovitis, cauterization of bleeding vessels of hemostasis, discoplasty,
removal of bone spurs and osteophytes, and discestomy. The major advantage of performing these procedures arthroscopically as opposed to as an open procedure is that
it is minimally invasive and results in less periarticular tissue disruption and better preservation of vascular and lymphatic drainage to the joint.14 By using the holmium:YAG
laser instead of conventional cutting instrument fluid, surgeon precision is increased
and diseased tisssue can be removed without mechanical contact, minimizing trauma

Fig. 3. (A) The OnPoint system is a small tube-like camera that projects the image onto
a monitor with video and audio capabilities. (B) The disposable fiberoptic scope tube is
approximately the size of an 18-gauge needle and is sterile packaged for single use.

Advances in Minimally Invasive TMJ Surgery

to the articular cartilage. Arthroscopic laser surgery also produces significantly less
tissue damage because the laser has less penetrance into surrounding tissue, allowing
a surgeon to cut and ablate tissue while minimizing iatrogenic damage.
Arthrocentesis and arthroscopy have filled a major gap in the armamentarium of oral
surgeons by providing a procedure to relieve pain and increase mobility in the joint for
patients not responsive to conservative treatment and not having to perform open joint
surgery. As the field has evolved, new techniques have made arthroscopy and arthrocentesis more successful, less invasive, and with fewer complications. In a recent
study, Israel and colleagues15 conducted a study analyzing the effects of TMJ arthroscopy early and later in patients clinical courses. They found that TMJ arthroscopy reliably decreased pain and increased the maximum interincisal opening distance in both
the early and late intervention groups. The early intervention group had better surgical
outcomes than the late intervention group. They concluded that arthroscopic surgery
should be considered earlier in the management of patients with inflammatory/degenerative TMJ disease. Israel and colleagues15 recommend, although a defined period
of nonsurgical therapy is necessary before consideration for surgical intervention,
continued treatment with non-surgical therapy that does not effectively relieve symptoms is not conservative. Arthroscopic surgery should be considered early in the
management of patients with inflammatory/degenerative TMJ disease.15
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