Journal of Cranio-Maxillo-Facial Surgery

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1 Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 Contents lists available at ScienceDirect Journal of Cranio-Maxillo-Facial Surgery journal homepage: The posterior double pass suture in repositioning of the temporomandibular disc during arthroscopic surgery: A report of 16 cases Carlos C. Goizueta Adame a, Mario F. Muñoz-Guerra b,c, * a Department of Oral & Maxillofacial Surgery, University Hospital Sant Joan, Carretera Alicante-Valencia s/n, Sant Joan d Alacant, Alacant, Spain b Department of Oral & Maxillofacial Surgery, University Hospital La Princesa, C/Diego de León 62, Autonoma University, Madrid, Spain c Department of Oral & Maxillofacial Surgery, University Hospital Monteprincipe, Avda. Monteprincipe 25, CEU-San Pablo University, Boadilla del Monte, Madrid, Spain article info abstract Article history: Paper received 21 November 2009 Accepted 28 January 2011 Keywords: Arthroscopy Temporomandibular joint Discopexy Aim: Several procedures have been described to reposition and secure the disc during arthroscopic surgery of the temporomandibular joint. The usefulness of these procedures remains controversial since simple lysis and lavage shows a high percentage of clinical success and it is difficult to obtain radiological imaging of the surgically acquired new disc position. This report describes a new arthroscopic discopexy method, and the clinical as well as radiological results obtained with this new technique. Methods: Sixteen patients with a clinical and radiological diagnosis of Temporomandibular Joint (TMJ) dysfunction (TMD) were treated using our discopexy method. Each patient was evaluated with a visual analogue scale (VAS) for pain, radiological and functional parameters. The evaluation also included a clinical examination. Each patient was recorded at baseline before surgery and at a one-year follow-up. Statistical analysis was performed to evaluate the differences in VAS, maximum opening and lateral movements before and after treatment and were considered statistically significant when p < Results: Patient evaluation showed an improvement in the clinical parameters. There were statistically significant reductions in the amount of pain according to the VAS (p < 0.01). Maximal interincisal opening (MIO) and contralateral translation movement (CTM) (p < 0.05) were substantially improved one-year after operation. In the post-surgical MRI study at the one-year follow-up, a significant improvement in the disc position was observed in 13 out of the 16 joints operated on. Conclusion: This method of arthroscopic disc repositioning is an effective surgical method for treating symptomatic patients with a diagnosis of TMJ disc displacement. Because of the minimally invasive character of the procedure, it should be considered in the surgical treatment of TMJ dysfunction. Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. 1. Introduction The role of anterior disc displacement (ADD) in TMD has been questioned in the literature. There is no general consensus on this matter and it remains a minor factor in the aetiopathogenesis of TMJ symptoms (limited opening and pain) (Goss, 1993; Dolwick, 1995; Hall, 1995). However, when the disc position is observed in magnetic resonance imaging (MRI) and the patient suffers pain, acute lock or chronic lock, difficulty in masticatory function or other symptoms, ADD is clearly an anatomical abnormality and the physician should try to improve the patients symptoms with surgical techniques, if the patient fails in the response to nonsurgical treatment. * Corresponding author. Department of Oral & Maxillofacial Surgery, University Hospital La Princesa, C/Diego de León 62, Autonoma University, Madrid, Spain. Tel.: þ ; fax: þ address: maxmferm@excite.com (M.F. Muñoz-Guerra). With advanced surgical arthroscopy, selected tissues within the TMJ can be treated avoiding damage to the remaining joint. Synovitis and adhesions can be treated using this technique, and disc mobilization can improve the clinical symptoms with this minimally invasive technique without scars. Using TMJ arthroscopy, capsulotomy and myotomy over the anteromedial area of the upper space can performed. Following this it is possible to stabilize the disc in the most lateral and posterior capsular zone. In the literature, several types of arthroscopic discopexy procedure (ADP) have been described. In these techniques a single suture passing once through the disc from the lower space was described by Israel (1989) and McCain et al. (1992a), whereas Tarro (1989) described the use of a suture to the external auditory canal. These techniques are difficult to perform and do not guarantee the disc position because they fix the disc with only one retention point. If the disc could be fixed at two points and sutured to the posterolateral capsule, the procedure would be more secure and the relationship of the disc, condylar head and /$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. doi: /j.jcms

2 C.C. Goizueta Adame, M.F. Muñoz-Guerra / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 87 Table 1 Characteristics of the patients, comparison of TMJ pain and articular function values between pre-surgery and one-year follow-up. MRI VAS Interincisal opening Lateral movement Patient Age Evolution Arthroscopic Pre-surgery Post-surgery Pre-surgery Post-surgery Pre-surgery Post-surgery Pre-surgery Post-surgery time (years) stage IV ADDW/OA ADDW/OA III ADDW ADDR IV ADDW ADDR III ADDR NDP IV ADDW/OA ADDW/OA III ADDW NDP IV ADDW ADDR IV ADDW NDP IV ADDW/OA ADDR IV ADDW ADDW/OA IV ADDW NDP III ADDW ADDR IV ADDW ADDR IV ADDW ADDR IV ADDW ADDR III ADDW NDP MRI - Magnetic resonance imaging, VAS - Visual analogic scale of pain, ADDW - Anterior disc displacement without reduction, ADDR - Anterior disc displacement with reduction, OA - Osteoarthrosis, NDP - Normal disc position. glenoid fossa could be improved during movement. Interposition of the disc between the condylar head and the glenoid fossa and retraction of the retrodiscal tissues could improve acute pain, support tissue regeneration and provide advantageous mechanical conditions. The purpose of this paper is to describe a new technique to retain the disc with two traction points in the posterior compartment. Our method is based on the Israel (1989) and McCain et al. (1992a) techniques. We report our results with clinical and radiological parameters. 2. Methods Our technique for ADP was initially developed by the authors who carried out the technique on the TMJ s of five adult human cadavers. Once satisfied with the procedure, sixteen patients (15 females and one male, average age 32, 8 years; range 17e49) were operated by the same surgeon (C.G.A.) at two different centres (Hospital Universitario Sant Joan D Alacant; Centro Clínico Medimar) using this new technique. Eighteen joints were treated, with two patients having a bilateral procedure. Postoperative follow-up was for over one-year in all cases Preoperative assessment and management All patients were evaluated according to a protocol which included pre surgical magnetic resonance imaging (MRI), evaluation of the pain using a visual analogue pain scale (VAS: 0e10) and measures of mandibular mobility. Sixteen joints had a clinical diagnosis of internal derangement with anterior disc displacement without reduction (ADDW) and this was confirmed by MRI. Two joints had anterior disc displacement with reduction (ADDR). Three of the joints had radiographic features of degenerative arthrosis (Table 1). Prior to surgery, all subjects had received a combination of pharmacotherapy (muscle relaxing and non-steroidal anti-inflammatory agents [NSAID]), occlusal bite plate therapy and physical therapy. In this group of patients, no history of previous surgical treatments on the TMJ was recognized. All the patients gave informed consent to participate in the trial Arthroscopic surgery Material Arthroscopy was carried out with a 2.2 mm Dyonics 30 arthroscope (Smith and Nephew, Melbourne, Australia). Two 2,3 mms cannulas were used to enter the superior joint space. The equipment for instrumentation consisted of alligator forceps, scissors, knife, blunt and feeler probes (Leibinger, Freiburg, Germany). A bipolar diathermy or a bipolar device Coblator II ENT (Arthrocare Corp, Sunnyvale, CA, USA) was used in to control bleeding, and also to cut and to ablate retrodiscal tissues. An epidural anaesthesia cannula marked in centimetres and with a curved tip (Tuohy/18; B. Braun, Melsungen, Germany) was used in the ADP procedure which was performed with a polydioxanone PDS 2/0 (resorbable nylon) suture, who s elastic properties and blue colour (easily identifiable in the monitor) were considered suitable for the procedure Repositioning of the TMJ disc In all cases, a standard TMJ arthroscopy was performed under general anaesthesia and nasotracheal intubation. Initially, the examination of the upper joint space was performed from posterior to anterior using a posterolateral portal (PL). Once the disc displacement had been assessed, access to the anteromedial zone was obtained using an anterolateral portal (AL). Adhesions were removed or lysed with the blunt instrument or with the knife. At this point, a capsulotomy with anterior myotomy using bipolar cautery or Coblator device was performed to widen the anterior space. Special care must be taken to avoid bleeding of the medial capsule. Next, a posterior mobilization of the disc was performed with a blunt probe, superficial thermo-synovectomy or a vaporization was carried out in the redundant retrodiscal tissues. Using these manoeuvres, complete exposure of the roof of the glenoid fossa and disc reposition are achieved, which is necessary to facilitate the next stage of the procedure. Using triangulation, a third portal (TP) was created approximately 10 mm in front of and 20 mms inferior to the PL (Fig. 1). Once the TP was secured, an 18 Tuohy needle was passed through it with a PDS 2/0 suture inside. The needle was then passed through the disc from lateral to medial through the disc convexity, piercing the disc initially on the lateral and then on the medial edges, until the tip of the needle was seen emerging in the posterior zone (Fig. 2). At this point in the procedure, the arthroscope was introduced into the AL portal, allowing the joint to be observed from the

3 88 C.C. Goizueta Adame, M.F. Muñoz-Guerra / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 Fig. 1. Three portals, posterolateral (PL) focussing disc convexity; anterolateral (AL) retaining disc against the condyle head in the assistant hand; third portal (TP) inferior and forward PL. Fig. 3. Alligator forceps taking hold suture from PL. (A) - Arthroscopic image (B) - External view. Fig. 2. Needle is leaving the disc on the medial region. anterior recess and the suture was grabbed with an alligator forceps inserted in the PL (Fig. 3). The needle was removed and the disc was now secured at two points, lateral and medial. The position and tension over the disc surface could now be observed directly. Normal disc movement was seen without clicking or opening restrictions (Fig. 4). The two ends of the PDS suture exited the skin at two separate sites (PL and TP). A small skin incision at TP was performed, with dissection of subcutaneous tissues. Using a French eye needle, the PL free end of the suture was passed to the TP point and a knot was made which was buried in the subcutaneous fatty tissue (Fig. 5). Finally, the superficial skin at TP point was closed with a 5/0 ethilon suture (Fig. 6). An intra-articular infiltration with sodium hyaluronate was always performed at the end of the procedure to support synovial fluid and to improve lubrication in the upper space Postoperative management All the patients received an intraoperative dose of amoxicillineclavulanic acid 1 g and dexametasone 8 mg. intravenously. Treatment at home was: Piroxicam 40 mg/12 h (four weeks), Omeprazole 40 mg/24 h (four weeks), and metamizol as analgesic/ 8 h only if pains. The procedure was followed by a course of functional rehabilitation which started on the second day (without opening the jaw more than 20 mm during the first three weeks) and continuing for at least six months. Soft diet was prescribed for at least two months, followed by a normal diet with the exception of very hard food. In the one-year post-surgery follow-up, the data recorded included maximal incisal opening (MIO), contralateral translation movement (CTM) and visual analogic scale of pain (VAS) Statistical analysis The ManneWhitney U test was used to compare the MIO, CTM and VAS before surgery and one-year post-surgery. Probabilities of less than 0.05 were accepted as significant. The data were analyzed using SPSS standard statistical package (SPSS Statistical Software, Chicago, IL, USA). 3. Results Operating time was between 40 and 90 min (average time- 50 min). In five cases, persistent intraoperative bleeding after myotomy occurred but it was resolved using the radiofrequency device (Coblator II) and did not interfere with the arthroscopic procedure. Transitory weakness in the frontal branch of the facial nerve was observed in three patients. Preoperatively 13 of patients had a MIO of <35 mm, and 14 had <7 mm of movement on lateral excursion. At the first review two weeks after surgery, all the patients had a VAS at least 5 points less than before surgery, and eight patients showed a VAS of 0. Most patients recovered rapidly, all patients used less than 4 analgesics (metamizol) in the first two weeks post-surgery.

4 C.C. Goizueta Adame, M.F. Muñoz-Guerra / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 89 Fig. 6. The knot is tied and retained into the subcutaneous tissue. Fig. 4. Drawing of a left TMJ with relations between probe, needle, suture and disc. (A) - Lateral view (B) - Anterior view. Fig. 5. Scheme of the way by means of which the suture is passed to the TP point from the PL. One-year after surgery, all cases had a MIO > 35 mm and 9 cases 40 mm (p < 0.05). The one-year assessment of the postoperative CTM showed all of the patients had lateral movements >7 mm and 12 cases 10 mm (p < 0.05). The patients experienced a significant improvement (p < 0.01) on the VAS with a range of 7e9 points (mean ) preoperatively, and 0e2 points (mean )postoperatively. The mean pain score improvement Fig. 7. MRI with complete repositioning of the TMJ disc. (A) - Presurgical view (B) - MRI one-year after surgery.

5 90 C.C. Goizueta Adame, M.F. Muñoz-Guerra / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 was 6.73 points. Pain was absent in 8 patients.no patient s pain was worse following treatment. In the post-surgical MRI study 13/16 cases showed improvement in the disc position - but only four cases showed a normal disc position (Fig. 7). 4. Discussion The ability to evaluate this technique with only three parameters and a short follow-up time is a drawback of this study, but these parameters (pain and movement) are the most important signs and symptoms to a patient with TMD. Because of this, they are good indicators of the success of the technique that we have described. The results of this paper show that all the patients treated with this procedure improved in the parameters that we measured and obtained normalization of joint movement. The VAS decreased in all the patients. One patient (case 5) had a complicated course, developing condylar osteoarthrosis eighteen months after surgery. At one-year post operatively, all the patients were felt to have had successful treatment if the following parameters were obtained: MIO more than 35 mms, CTM more than 8 mms and VAS less than 25. Other techniques (arthrocentesis, lysis and lavage, arthroscopy, advanced arthroscopy techniques without disc suturing) have obtained success rates of between 79% and 93% in range of movement improvement and decreases in pain (Nitzan et al., 1990; McCain et al., 1992b). These studies show longer follow-up periods and shorter term symptoms than the in patients that our study. Disc repositioning has been associated with pain relief, but the new position of the disc after TMJ disc repositioning surgery has not been demonstrated in MRI studies, nor have suturing techniques been shown to be effective in the recent clinical literature (Lundh et al., 1988; Montgomery et al., 1992). A recent study by Zhang et al. (2010) based on 764 joints treated with an arthroscopic suturing technique showed excellent improvement in the disc position on MRI in 95.42% of the cases. However, this Chinese paper did not adequately describe the suturing technique. According to several authors, the results of TMJ invasive treatment do not depend of the final disc position (Nitzan et al., 1991; Dolwick, 1995; Israel et al., 2006). It has been shown that asymptomatic disc displacement in the TMJ is common in the general population (Ribeiro et al., 1997). These arguments support the idea that recapture of the disc, with or without suture, is not useful, because disc position is not an important factor in joint pathology, and treatment of the pathological changes (osteoarthritis, synovitis, adherences) in TMD without disc mobilization should be enough to improve all symptoms. Contrary to these studies, other research suggests that disc mobilization in combination with the management of pathological changes gives better results and possibly reduces or prevents posterior condylar degeneration (Conway et al., 1991; McKenna et al., 1996). Disc mobilization may be important only in supporting the regeneration of tissues and improving mechanical function. Although the postoperative disc position may change soon after surgery, this is not necessarily a relapse. In an MRI study of the knee in 62 asymptomatic volunteers 4% of the joints had abnormalities in at least three of the four regions of the knee (Beattie et al., 2005). Other studies have also shown that asymptomatic volunteers have abnormal MRI images with meniscal tears, bone oedema, effusions and other pathological changes (Boden et al., 1992; Major and Helms, 2002). For knee arthroscopists, an MRI showing a torn meniscus in a painful joint is the main finding in a knee with osteoarthritis. The objective of knee arthroscopy in these cases is fixation and stabilization of the meniscus. Arthroscopic surgery in other joints attempts to improve mechanical problems caused by a torn meniscus or torn ligaments using sutures, pins, anchors and grafts. Debridement and smoothing of the joint surfaces are used in the management of OA but there is not, for example, any efficient treatment for chondromalacia (Brukner et al., 2006). Tissue regeneration depends on a number of non-surgical factors. The goal in peripheral joint arthroscopy is normally to improve a mechanical problem and subsequently the pain problem. Arthroscopic surgical procedures using shavers to clean and to widen spaces in OA are an attempt to delay the use of a prosthesis. Considering these principles we believe that the goal of TMJ arthroscopic surgery in TMD should be to improve biomechanical efficiency in the upper joint space. The treatment of synovitis, adhesions and osteoarthritis is part of the surgical procedure and should be always performed. Some arthroscopic disc suturing techniques have been used previously: Tarro (1989) described a blind suture and fixation to the external acoustic meatus. Israel (1989) described the passing of a needle infero-superiorly from the lower space and McCain et al. (1992a) developed a similar technique later. Our technique, based on these techniques, has several advantages: - The surgeon can see directly what he is doing during throughout the procedure there is no time when he cannot see directly what is happening. - No damage is made to the surface of the condylar head avoiding scars and possible late degenerative changes in the cartilage. - The condyle is not perforated avoiding possible medullary or vascular damage. - The disc is not fixed to the condylar head. The TMJ is a diarthrodial joint. The result of securing disc to the condyle could transform it into a monoarthrodial joint. - The disc is fastened to the capsular tissue with two vectors from two traction points opposite the area where the myotomy is performed. - The tension over disc is clearly observed in the surgical procedure, and the new relationship can be observed once the procedure is completed. Nevertheless, it also has disadvantages: - The surgeon needs considerable experience and training to obtain three portals into the TMJ. - When carrying out the first few cases it is difficult to choose the best zone for disc puncture. - Changing instruments in the cannulas can be difficult if the surgeon and the assistant are not very trained together. - Puncture of the disc must be done carefully and the distance between the two puncture points must be wide enough to obtain two traction points avoiding the damage of the disc. The number of patients involved in this study is too small to confirm that this is a safe and reliable technique for general use in the management of patients with symptomatic TMD. In order to confirm this we plan to carry out a prospective, randomized study with more complete clinical parameters and MRI control in a larger group of patients to demonstrate the stable position of disc and the safety of the technique. 5. Conclusion The goal of surgery in TMD is to improve biomechanical function in the upper joint space. This new arthroscopically-assisted disc repositioning-technique is an effective surgical method for the improvement of joint function and reduction of pain in patients

6 C.C. Goizueta Adame, M.F. Muñoz-Guerra / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 86e91 91 with a diagnosis of disc displacement with or without reduction. Because of the minimally invasive character of the procedure, it should be considered as a technique for use in the surgical treatment of the TMJ. Long-term radiological and clinical studies would be useful to confirm their effectiveness. Acknowledgements The authors thank to Francisco-José Rodriguez Campo for their technical and artistic support. References Beattie KA, Boulos P, Pui M, O Neill J, Inglis D, Webber CE, et al: Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis Cartilage 13(3): 181e186, 2005 Boden SD, Davis DO, Dina TS, Stoller DW, Brown SD, Vailas JC, et al: A prospective and blinded investigation of magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects. Clin Orthop Relat Res 282: 177e185, 1992 Brukner PD, Crossley KM, Morris H, Bartold SJ, Elliott B: Recent advances in sports medicine. Med J Aust 184(4): 188e193, 2006 Conway WF, Hayes CW, Campbell RL, Laskin DM, Swanson KS: Temporomandibular joint after meniscoplasty: appearance at MR imaging. Radiology 180(3): 749e753, 1991 Dolwick MF: Intra-articular disc displacement part I: its questionable role in temporomandibular joint pathology. J Oral Maxillofac Surg 53(9): 1069e1072, 1995 Goss AN: Toward and international consensus on temporomandibular joint surgery. Report of the second international consensus meeting, April 1992, Buenos Aires, Argentina. Int J Oral Maxillofac Surg 22(2): 78e81, 1993 Hall HD: Intra-articular disc displacement part II: its significance role in temporomandibular joint pathology. J Oral Maxillofac Surg 53(9): 1073e1079, 1995 Israel HA: Technique for placement of a discal traction suture during temporomandibular joint arthroscopy. J Oral Maxillofac Surg 47: 311e313, 1989 Israel HA, Langevin CJ, Singer MD, Behrman DA: The relationship between temporomandibular joint synovitis and adhesions: pathogenic mechanisms and clinical implications for surgical management. J Oral Maxillofac Surg 64(7): 1066e1074, 2006 Lundh H, Westesson PL, Jisander S, Eriksson L: Disk-repositioning onlays in the treatment of temporomandibular joint disc displacement: comparison with a flat occlusal splint and with not treatment. Oral Surg Oral Med Oral Pathol 66(2): 155e162, 1988 Major NM, Helms CA: MR imaging of the knee: findings in asymptomatic collegiate basketball players. AJR Am J Roentgenol 179(3): 641e644, 2002 McCain JP, Podrasky AE, Zabiegalski NA: Arthroscopic disc repositioning and suturing: a preliminary report. J Oral Maxillofac Surg 50(6): 568e579, 1992a McCain JP, Sanders B, Koslin MG, Quinn JH, Peters PB, Indresano AT: Temporomandibular joint arthroscopy: a 6-year multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg 50: 926e930, 1992b McKenna SJ, Cornella F, Gibbs SJ: Long-term follow-up of modified condylotomy for internal derangement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81(5): 509e515, 1996 Montgomery MT, Gordon SM, Van Sickels JE, Harms SE: Changes in signs and symptoms following temporomandibular joint disc repositioning surgery. J Oral Maxillofac Surg 50(4): 320e328, 1992 Nitzan DW, Dolwick MF, Heft MW: Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg 48(8): 798e801, 1990 Nitzan DW, Dolwick MF, Martinez GA: Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 49(11): 1163e1167, 1991 Ribeiro RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, Magalhaes AC, et al: The prevalence of disc displacement in symptomatic and asymptomatic volunteers aged 6e25 years. J Orofac Pain 11(1): 37e47, 1997 Tarro AW: Arthroscopic treatment of anterior disc displacement: a preliminary report. J Oral Maxillofac Surg 47(4): 353e358, 1989 Zhang SY, Liu XM, Yang C, Cai XY, Chen MJ, Haddad MS, et al: Suturing technique for treating internal derangement of the temporomandibular joint: part IIdmagnetic resonance imaging evaluation. J Oral Maxillofac Surg 68(8): 1813e1817, 2010