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Surgical anatomy of tmj
PRESENTATION BY:
Dr. Minal Sonare
Junior resident 1 st year
Department of Oral and maxillofacial surgery
1
 Introduction
 Basic Anatomy
 Relations of Tmj
 Movements of Normal Tmj
 Associated surgical anatomy
 Various surgical approaches and their modifications
 Complications
 References
2
INTRODUCTION:
• The tmj is a ginglymoarthrodial joint, a term that is derived
from ginglymus, meaning a hinge joint, allowing motion only
backward and forward in one plane, and arthrodia, meaning
a joint of which permits a gliding motion of the surfaces.
• The most important functions of the temporomandibular
joint are mastication and speech .
• Craniomandibular joint -Articulation between the
condylar head of mandible and the anterior part of the
glenoid fossa of two temporal bones.
• Frequently termed as tmj
• Acts like class III lever
• Embryology - In contrast to other diarthrodial joints
TMJ is last joint to start develop, in about 7th week in
utero. It develops from condensation of temporal and
condylar blastemata each has its own joint cavity hence
there are two spaces in joint .
• Bilateral diarthrosis – right & left function together
• Only joint in human body to have a rigid endpoint of
closure that of the teeth making occlusal contact.
• Compound joint
• Complex joint
• only ellipsoid type of synovial joints with an articular
disc and articular surfaces are covered by
fibrocartilage instead of hyaline cartilage- can handle
better shear forces due to occlusal load.
Peculiarity of TMJ :
BASIC ANATOMY :COMPONENTS
• Mandibular condyle
• Articular surfaces of Temporal bone
• Articular disc
• Capsule
• Ligaments
• Muscular component
The Mandibular Condyle
• An ovoid process
• It is convex in all directions but wider L-M (15 to 20 mm)
than A-P (8 to 10mm).
• The medial pole extends sharply inward and is directed
more posteriorly. lateral pole is rough, bluntly pointed
• Elliptical in shape, long axis angled backward between 15
– 33 to frontal plane
• Thus, if the long axes of two condyles are extended
medially, they meet at approximately at the basion
forming an angle that opens toward the front ranging
from 145 to 160
• articular surface lies on its anterosuperior aspect
Articular surfaces of Temporal bone
• situated on the inferior aspect of temporal squama anterior
to tympanic plate.
• Articular eminence: transverse bony bar that forms the
anterior root of zygoma.
• Articular tubercle: this is a small, raised, rough, bony knob
on the outer end of the articular eminence.
• Preglenoid plane: slightly hollowed, almost horizontal,
articular surface
Articular disc
• Biconcave fibrocartilaginous structure located between
• Divides the joint into a larger upper compartment and a
smaller lower compartment
• Its function is to accommodate a hinging action (lower
compartment )as well as the gliding actions(upper
compartment)
• Shape -Roughly oval, firm, fibrous plate.
• Anterior band = 2 mm in thickness, Posterior band = 3 mm
thick,Thin in the centre intermediate band of 1 mm thickness.
• More posteriorly there is a bilaminar or retrodiscal region.
• Superior surface - saddle-shaped ; inferior surface - concave
Articular disc
• The disc is attached all around the joint capsule except for the strong
straps
• Anteriorly - attached to a fibrous capsule superiorly and inferiorly.
• Posteriorly -the bilaminar region consists of two layers of fibers
separated by loose connective tissue.
• Upper layer or temporal lamina -composed of elastin and is attached to
the postglenoid process. It prevents slipping of the disc while yawning.
• Inferior layer - curve down behind the condyle to fuse with the capsule
and back of the condylar neck. It prevents excessive rotation of the disc
over the condyle.
Fibrous Capsule
• Thin sleeve of tissue completely surrounding joint.
• Extension- the circumference of the cranial
articular surface to the neck of the mandible.
• The outline – anterolaterally to the articular tubercle, laterally to the lateral rim of the
mandibular fossa, posterolaterally to the postglenoid process, posteriorly to the posterior
articular ridge, medially to the medial margin of the temporal, anteriorly it is attached to
the preglenoid plane
• Medially and laterally- blends with the condylodiscal ligaments
Fibrous Capsule
• Area of relative weakness in the anterior capsular lining becomes a
source of possible herniation of intraarticular tissues, and this, in
part ,may allow forward displacement of the disk.
• Synovial membrane lining the capsule covers all the intra-articular
surfaces except the pressure-bearing fibrocartilage.
• Four capsular or synovial sulci -the posterior and anterior ends of
the upper and lower compartments which changes shape during
translatory movements.
Ligaments •Three functional ligaments :
The collateral ligament
The capsular ligament
The temporomandibular ligament
•Two accessory ligaments:
The sphenomandibular ligament
The stylomandibular ligament
Collateral ligaments
• The ligament on each side of the jaw in two distinct layers.
• The wide outer or superficial layer is usually fan-shaped and
arises from the outer surface of the articular tubercle and
most of the posterior part of the zygomatic arch.
• The ligamentous fascicles run obliquely downward and
backward to be inserted on the back, behind, and below the
mandibular neck.
Lateral/Temporomandibular ligament
• Main stabilizing ligament - thickened capsule - collagen
fibers
• Course: Down & back attached above to articular eminence
, below to outer & post side of neck of condyle, Posterior
fibers unite with capsule
• Function: limits protraction , inferior distraction ,posterior
movement of condyle
• Specific length & poor ability to stretch- maintains integrity
& limits movement of TMJ (mainly anterior excursion &
prevents posterior dislocation – CHECK LIGAMENT
• Slippage of condyle:medially prevented by glenoid process ,
laterally by TM ligament
Sphenomandibular ligament
• Arises from the angular spine of the sphenoid and
petrotympanic fissure. Runs downward and
outward.Insert on the lingula of the mandible.
• The ligament is related – Laterally - lateral
pterygoidmuscle. Posteriorly - auriculotemporal nerve.
Anteriorly - maxillary artery. Inferiorly - the inferior
alveolar nerve and vessels a lobule of the parotid gland.
Medially - medial pterygoid with the chorda tympani
nerve and the wall of the pharynx with fat and the
pharyngeal veins intervening.
• The ligament is pierced by the mylohyoid nerve and
vessels.
• This ligament is passive during jaw movements
Stylomandibular ligament
• a specialized dense, local concentration of deep cervical
fascia extending from the apex and being adjacent to the
anterior aspect of the styloid process and the stylohyoid
ligament to the mandible’s angle and posterior border.
• This ligament then extends forward as a broad fascial layer
covering the inner surface of the medial pterygoid muscle.
• The anterior edge - thickened and sharply defined.
• Relaxes when the jaws are closed and slackens noticeably
when the mouth is opened
• This ligament becomes tense only in extreme protrusive
movements.
Muscular component
• The masticatory muscles surrounding the
joint are groups of muscles that contract
and relax in harmony so that the jaws
function properly.
• When the muscles are relaxed and flexible
and are not under stress, they work in
harmony with the other parts of the tmj
complex.
• The muscles of mastication produce all the
movements of the jaw.
Surgical anatomy of tmj
Vascularisation : Arterial Supply
• Branches of external carotid artery
• Superficial temporal artery
• Deep auricular artery
• Anterior tympanic artery
• Ascending pharyngeal artery
• Maxillary artery
• The blood supply to TMJ is only superficial, i.e.
There is no blood supply inside the capsule
• TMJ takes its nourishment from synovial fluid
Vascularisation : Venous Supply
•Venous plexus
•Maxillary vein
•Tranverse facial vein.
•Superficial temporal vein.
Nerve Supply :
•Auriculotemporal
•Deep temporal
•Massetric nerve
Relations of Tmj : Anteriorly
• Mandibular notch, lateral pterygoid muscle, masseteric nerve
and artery
• A careful dissection of 16 intact human cadaveric head
specimens revealed the location of the masseteric artery was
then determined in relation to 3 points process:
1 ) the anterior-superior aspect of the condylar neck = 10.3 mm
2 ) the most inferior aspect of the articular tubercle = 11.4 mm;
3 ) the inferior aspect of the sigmoid notch = 3 mm.
Relations of Tmj : Posteriorly
• Parotid gland
• Superficial temporal vessels
• Auriculotemporal nerve
Relations of Tmj : Medio-laterally
• Medially -Tympanic plate (separates from
ICA) ,Spine of sphenoid,Auriculotemporal
& chorda tympani nerve,Middle
meningeal artery ,Maxillary artery
• Laterally – Skin and fascia Parotid gland
Temporal branches of facial nerve
Relations of Tmj : Supero-Inferiorly
Superiorly – middle cranial fossa
middle meningeal vessels
Inferiorly – maxillary artery & vein
TMJ Movement :
• Rotational / hinge movement in first 20-25mm of mouth
opening and Translational movement after that when
the mouth is excessively opened.
• Translatory movement – in the superior part of the joint
as the disc and the condyle traverse anteriorly along the
inclines of the anterior tubercle to provide an anterior
and inferior movement of the mandible.
• Hinge movement – the inferior portion of the joint
between the head of the condyle and the lower surface of
the disc to permit opening of the mandible.
TMJ Movement :
• Depression Of Mandible- Lateral pterygoid
Digrastric Geniohyoid Mylohyoid
• Elevation of Mandible - Temporalis Masseter
Medial Pterygoids
• Protrusion of Mandible - Lateral Pterygoids
Medial Pterygoids
• Retraction of Mandible- Posterior fibres of
Temporalis
Lubrication Of The Joint
• The synovial fluid comes from two sources: first, from plasma by dialysis, and second, by secretion
from type A and B synoviocytes with a volume of no more than 0.05 ml.
• • However, contrast radiography studie - the upper compartment could hold approximately 1.2 ml
of fluid without undue pressure being created, while the lower has a capacity of approximately 0.5
ml.
• It is clear, straw-colored viscous fluid.It diffuses out from the rich capillary network of the
synovial membrane.
• Contains: Hyaluronic acid which is highly viscous ,May also contain some free cells mostly
macrophages.
• Functions: • Lubricant for articulating surfaces. • Carry nutrients to the avascular tissue of the
joint. • Clear the tissue debris caused by normal wear and tear of the articulating surfaces.
3
1
Facial Nerve :
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
 Liebman et al in 1982, described histologically that the layer in
which it travels.
They reported that it was locked in the fascial layer between temporalis
fascia and subdermal fat superficially.
 Stuzin et al in 1988, examined the temporal region by cadaver
dissection and reported that it lay within the temporoparietal fascia
and travels along undersurface of this fascial layer.
35
Temporoal Branch :
A straight trajectory A curved trajectory.
TEMPORAL BRANCHES OF
FACIAL NERVE
Ishikawa Y:An anatomical study on the distribution of the temporal branch of the facial
nerve.
36
Pitanguy, L, A. S. Ramos: The
frontal branch of the facial
nerve: The importance of its
variation in face lifting.
Plast. Reconstr. Surg. 38 (1966)
352
MIDDELTON’S
LINE
37
The new guideline for preservation of
the entire temporal branch is drawn
with a dashed line.
38
J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
Dingman and Grab
Ziarah andAtkinson
39
Superficial temporal artery
Transverse facial artery
Maxillary artery
40
7-Mar-17
Atlas of human anatomy – Frank H Netter 6th ed
41
Auriculotemporal
nerve
Auriculotemporal
nerve
ARISES FROM POSTERIOR PART OF
MANDIBULAR DIVISION OF CN V
41
Atlas of human anatomy – Frank H Netter 6th ed
Runs beneath lateral pterygoid muscle.
Passes from medial surface of condyle &
emerges on to the face behind the TMJ
within the superior surface of the parotid
gland.
Ascends posterior to the superficial
temporal vessels, passes over the posterior
root of the zygoma, and divides into
superficial temporal branches
Superficial temporal vein
Maxillary vein
Retromandibular vein
Anterior division
Posterior division
42
GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
largest ascending branch of the cervical plexus
arises from the second and third cervical rami,
encircles the posterior border of
sternocleidomastoid,
perforates the deep fascia and ascends on the
muscle beneath platysma
On reaching the parotid gland, it divides into
anterior and posterior branches
43Greater auricular nerve
44
 Temporomandibular joint and its components frequently require exposure for a myriad of procedures.
Extraoral approaches
1. Preauricular
2. Endaural
3. Postauricular
4. Coronal
5. Retromandibular
6. Submandibular
7. Rhytidectomy 45
Intraoral approaches
1. Intraoral vestibular –
without endoscope
with endoscope
 Concept given by Teisser & defined by
Mitz and Peyronie in 1976.
 Continuous fibromuscular layer.
 Synonyms:
 In scalp – galea aponeurotica
 In temporal region – temporoparietal
fascia, superficial temporal fascia or
suprazygomatic SMAS
 Below zygomatic arch –
parotideomasseteric fascia
46
Superficial Musculoaponeurotic System
Accessibility to the joint
Avoiding damage to vital neurovascular structures
Aesthetic concerns on visibility of post op scars
Technique sensitivity and surgeon’s experience
In case of ankylosis, choice of interpositioning
material.
47
48Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Pre-Auricular Incision :
49
INCISION IS OUTLINED AT THE
JUNCTION OF FACIAL SKIN
AND HELIX OF THE EAR.
• SUPRAFASCIAL PROCEDURE
-ROWE NL: SURGERY OF THE TEMPORO-MANDIBULAR JOINT.
PROC R SOC MED 65:383, 1972
•SUBFASCIAL PROCEDURE
-AL-KAYAT A, BRAMLEY P:AMODIFIED PRE-AURICULAR
APPROACH TO THE TEMPOROMANDIBULAR JOINT AND MALAR
ARCH. BR J ORAL SURG 17:91, 19
•DEEP SUBFASCIALAPPROACH
- MASSIMO POLITI : J ORAL MAXILLOFAC SURG 62:1097-1102, 2004
• Incising temporalis fascia
• Make an oblique incision (450)parallel to the frontal branch of the facial nerve(2 cm below
the malar arch), through the superficial layer of the temporalis fascia above the zygomatic
arch.
• Begins at the root of zygomatic arch and extends anterosuperiorly towards upper corner of
reflected flap
51
Coronal view of dissection to the lateral
portion of the zygomatic arch and
mandibular condyle region.
Insert the periosteal elevator beneath the
superficial layer of the temporalis fascia
and strip the periosteum off the lateral
zygomatic arch.
52
53
Blunt dissection below the
zygomatic arch
Exposed TMJ capsule
54
First incision is through the upper joint space followed by the lower joint incision
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
55
Blair’s Inverted Hockey
Stick – angulated
superiorly
Dingman’s Incision-
preauricular crease
Endaural Incision-
lies in ear cartilage
Popowich and Crane
Incision-question mark
shaped incision line goes into
the hairline
Thoma’s Angulated Incision-
angulated at 450
56
Modification
of
preauricular
approach
Skin incision is question mark shaped
Begins antero-superiorly within the
hairline & curves backwards and
downwards well posterior until it meets
upper ear attachment
Incision then follows ear attachment
endauraly
57
58
 Advantage:
 less bleeding
 fascial planes can be
easily identified
 excellent
visibility
 good cosmetic
result
59
 Incision is started in the fold at
the junction of anterior margin
of helix
 Carried downwards to upper
portion of tragus where it is
contained inside the margin of
tragus to anterior fold of lobule
 It again becomes visible at this
point and is carried downwards
to lower attachment of ear
60
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
61
FIRST DESCRIBED BY
LEMPART AS AN APPROACH
TO MASTOID PROCESS FOR
SURGICAL IMPROVEMENT
OF OTOSCLEROSIS FOR
APPROACHING TMJ
Incision begins well within the EAM at superior meatal
wall
The incision is carried carefully through the skin over the
tragal cartilage at a 90- degree angle to the most convex
part of the tragus itself.
The incision is carried superiorly to the uppermost
portion of the auricle and then extends in approximately
a 45 degree angle into the temporal hairline for about 3
to 4 cm.
62
63
Comparison of standard preauricular
and endaural surgical approaches
Advantages:
• Most of the vital structures are in a superficial
plane.
• Very good access to the joint and also the
coronoid process.
• Excellent esthetic result with minimal post
operative scar
Disadvantage:
• Esthetic compromise if tragal projection is lost
• Risk of possible perichondritis
64
ADVANTAGES:
• Broad based flap with excellent
blood supply
• Possibility of residual cartilaginous
deformity is less
• Damage to CN VII is unlikely
65
667
Excellent Healing
 Descibed by Alexander & James
 Incision is placed in the grove between the helix
and post auricular skin
 Pre-op considerations described by Walter and
Geist:
1. History of normal scar formation
2. Healthy auditory system with no infection
3. No TMJ infection
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
67
68
3-5cm incision is made parallel & posterior
to postauricular flexure
Begins at superior aspect of external pinna
and extended till the tip of mastoid process
Dissection is done through posterior
auricular muscle to the level of mastoid
fascia
Transected auditory canal closure of auditory canal
Final closure of the incision. 69
ADVANTAGES
 Predictability of anatomic
exposure
 Excellent surgical exposure of
the bilaminar zone and the
mandibular condyle
posteriorly
 Cosmetic superiority
 Less risk of CN VII injury
 Dissection is more rapid
70
DISADVANTAGES
 Not advised in patients
susceptible to keloid
 Infection
 Meatal stenosis can occur
 Anterior exposure is
limited
 versatile surgical approach to the upper and middle regions of the
facial skeleton, including the zygomatic arch and TMJ.
 major advantage of this approach is that most of the surgical scar
is hidden within the hairline.
71
Surgical anatomy of tmj
LAYERS OF THE
SCALP
BELOW THE
SUPERIOR
TEMPORAL LINE
74
Incision placement for patients with male pattern
hair recession. The incision is stepped posteriorly
just above the attachment of the helix of the ear
Incision placement for most female patients.
The incision is kept approximately 4 cm
behind the hairline
75
THE INCISION IS THROUGH THE SKIN,
SUBCUTANEOUS TISSUE, AND GALEA REVEALING
THE SUBGALEAL PLANE OF LOOSE AREOLAR
CONNECTIVE TISSUE OVERLYING THE
PERICRANIUM
76
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
77
The skin incision below the superior
temporal line should extend to the
depth of the glistening superficial
layer of the temporalis fascia,
into the subgaleal plane, continuous
with the dissection above the
superior temporal line.
78Surgical approaches to facial skeleton – Edward Ellis 2nd ed
79
Along the lateral aspect of the skull, the
glistening white temporalis fascia
becomes visible where it blends with the
pericranium at the superior temporal
line.
The plane of dissection is just
superficial to this thick fascial sheet
Near the ear, the flap is dissected
inferiorly to the root of the
zygomatic arch by incising
superficial layer of temporalis
fascia
The lateral portion of the
flap is dissected inferiorly
atop the temporalis fascia
EXPOSURE OF THE
TEMPOROMANDIBULAR JOINT:
81
Access to the TMJ region is gained by
dissecting below the zygomatic arch anterior
to tragal cartilage.
Masseter is detached from the zygomatic arch
exposing the sigmoid notch and TMJ
capsule.
Capsule is then incised exposing the TMJ.
CLOSURE: DONE IN LAYERS
82
 Closure of TMJ capsule is done followed by closure of
temporalis fascia .
 Superficial layer of the temporalis fascia, which is
incised during the approach, is sutured approximately 1
cm superior to the superior edge of the incised fascia.
 Galea is closed as a distinct layer.
 Scalp incision is closed.
The coronal incision has been modified.
The principal difference involves the position of the skin incision –
• placed behind the ear.
• use of a zigzag incision instead of a straight incision within the hairline.
The initial incision is carried through the skin and subcutaneous tissues to
the level of the platysma muscle.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Incision usually starts 1.5-2cm inferior to the lower border of mandible.
Submandibular
Or Risdon
Approach
Dissection of platysma and exposure of superficial layer of
deep cervical fascia
85
dissection to the pterygomasseteric muscular sling
86
Associated anatomic structures
87Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Dissection is performed
through the fascia at the level
of the initial skin incision,
followed by dissection
superiorly to the level of the
periosteum of the mandible
88
With retraction of the dissected
tissues, the inferior border of
the mandible is seen.
89Surgical approaches to facial skeleton – Edward Ellis 2nd ed
The pterygomasseteric sling is
sharply incised with a scalpel
along the inferior border
90Surgical approaches to facial skeleton – Edward Ellis 2nd ed
THE MASSETER AND MEDIAL
PTERYGOID MUSCLES ARE
SUTURED TOGETHER
subcutaneous tissues and skin
closure is done
91
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
92
 exposes the entire ramus from behind the
posterior border.
 therefore may be useful for procedures
involving the area on or near the
Condylar neck/head or the ramus itself
93
 ADVANTAGES: close proximity to the condylar area
 DISADVANTAGES: passing through the parotid gland tissue,
thus increasing the risk of facial nerve
injury and salivary fistulae.
94
95Surgical approaches to facial skeleton – Edward Ellis 2nd ed
96
Blunt dissection
97
 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
98Surgical approaches to facial skeleton – Edward Ellis 2nd ed
APPROXIMATING
PTERYGOMASSETERIC SLING
99
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Closure of parotid capsule
JORALMAXILLOFACSURG67:2418-2424, 2009
100
1. Smaller scar as access was limited to 2cm only.
2. Plane of dissection was superficial to SMAS.
3. Risk of Frey’s syndrome, sialocoele and salivary fistula
can be eliminated.
4. Surgical site is always perpendicular to fracture site.
5. Integrity of joint is always maintained.
101
 Also called as facelift
approach.
 Variant of retromandibular,
transmasseteric -
anteroparotid approach
102
 When using the rhytidectomy approach, the structures
that should be visible in the field include –
1. the corner of the eye,
2. the corner of the mouth, and the lower lip anteriorly,
3. the entire ear and descending hairline, and 2 to 3 cm of
hair superior to the posterior hairline, posteriorly
4. the temporal area must also be completely exposed
superiorly
103
The incision begins approximately
1.5 to 2 cm superior to the zygomatic arch just
posterior to the anterior extent of the hairline.
The incision then curves posteriorly and
inferiorly, blending into a preauricular incision
in the natural crease anterior to the pinna.
The incision continues under the earlobe and
approximately 3 mm onto the posterior surface
of the auricle instead of continuing in the
mastoid–ear skin crease.
It curves posteriorly toward the hairline and
then runs along the hairline, or just inside it,
for a few centimeters.
104Surgical approaches to facial skeleton – Edward Ellis 2nd ed
105Surgical approaches to facial skeleton – Edward Ellis 2nd ed
106
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
107
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
108
109
Gap arthroplasty for temporomandibular joint ankyloses by transoral approach: A case series
Int. J. Oral Maxillofac Surg
AD:
• better visibility
• access to high level fracture
using transbuccal trocar.
110
Once the capsule has been identified, access to the
articular surfaces (superior and inferior joint spaces)
can be obtained by a great variety of incisions.
111-
;
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
112
The lateral ligament, capsule, and
periosteum are reflected inferiorly
en masse.
Discal or posterior attachment are
dissected sharply with scissors to
the level of the condylar neck.
113
The posterior attachment and disc attachments are then severed sharply at the
lateral pole of the condyle from within the developed flap.
These tissues are then reflected superiorly from the head of condyle to expose
inferior joint space
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
The superior joint space is
punctured at the level of
discocapsular sulcus.
A dissection is then carried inferiorly
removing the attachment of the
capsule to the disc and exposing the
inferior joint space.
114
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
115
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
116
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
1. Poor facial scar
2. Infection
3. Wound dehiscence
4. Facial nerve palsy
5. Perichondritis
6. Sialocoele
7. Frey’s syndrome
117
Surgical anatomy of tmj
119
SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration
 MANAGEMENT:
1. Conservative: mildest form is treated by using oral and topical
antibiotics.
2. Hematoma of the auricle should be drained properly
3. If there is any sign of pus drainage – C/S followed by broad
spectrum IV antibiotics.
4. In resistant cases, continuous drainage and irrigation with
antibiotics and steroids solution.
5. In severe cases, aggressive excision of the necrosed cartilage
involving overlying subcutaneous tissues and skin should be
done.
121
 Sialocoeles result in the
accumulation of saliva in
glandular/periglandular or
subcutaneous tissues.
 When the accumulated
saliva drain through the
skin it is termed as
salivary fistula.
122
MANAGEMENT
1. Small sialocoeles have said to resolve spontaneously by scar
formation which seals the salivary flow.
1. Non surgical management:
 repeated aspirations and compression dressings
 administration of anticholinergics
 antisialogogues
123
Surgical management:
These procedures direct the salivary flow into
the mouth or
Depresses the salivary secretion
1. Creating a tract intraorally
2. Duct ligation
3. Sectioning of auriculotemporal nerve
4. Surgical excision of fistulous tract
124
125
J Oral Maxillolac Surg49:680-682. 1991
NAMED AFTER DR. LUCIA
FREY
Frey’s syndrome or gustatory sweating and flushing is characterized
by sweating and flushing of the facial skin during meals.
The area involved is on the lateral aspect of the face and upper neck,
usually around the parotid region.
 Techniques to evaluate - Blotting paper method
Iodine sublimated paper histogram
Treatment:
1. external radiotherapy
2. local or systemic application of anticholinergic drugs
Laage-Hellman was the first to apply scopolamine (3%
cream) for the treatment of gustatory sweating.
1. interposition of a subcutaneous barrier
2. injection of botulinum toxin in the involved skin
126
 Surgical Interposition
the use of a barrier between the facial skin and
the parotid bed.
127
 Botulinum Toxin
The injection of botulinum A toxin in the skin involved
by gustatory sweating was recently proposed by Drobik and
Laskawi. It acts by blocking the exocytosis mechanism of
the presynaptic terminal, thereby inhibiting release of
acetylcholine.
 Know your anatomy properly.
- Emphasis on Facial .N relation to fascial layers.
 Importance of maintaining proper dissection
plane.
 Chose the appropriate approach based on the
problem.
 Be aware of the possible complications from each of
the approach.
1. GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
2. Atlas of human anatomy – Frank H Netter 6th ed
3. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
4. Oral and maxillofacial trauma – Fonseca 4th ed
5. Surgical approaches to facial skeleton – Edward Ellis 2nd ed
6. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
7. Salivary gland disorders - Myers
8. An Anatomical Study on the Distribution of the Temporal Branch ofthe
Facial Nerve - J. Cranio-Max.-Fac. Surg. 18 (1990) 287-292.
9. A modified pre-auricular approach to the temporomandibular jointand
malar arch - British Journal of Oral Surgery 17 (1979-80), 91-103.
10. The surgical anatomy of the mandibular distribution of the facial nerve
British Journal of Oral Surgery (1981) 19, 159-l 70. 129
 AModified EndauralApproach to the Temporomandibular JointOral Maxillofac
Surge 51:33-37,1993.
 A new modified endaural approach for access to the temporomandibularjoint
British Journal of Oral and Maxillofacial Surgery (2001) 39, 371–373.
 The Deep Subfascial Approach to the Temporomandibular Joint - J Oral
Maxillofac Surg 62:1097-1102, 2004.
 Ankylosis of temporomandibular joint - Dingman
 A truly endaural approach to the temporo-mandibular joint - British Journal of
Plastic Surgery (1984) 37,65-68.
 Transmasseter Approach to Condylar Fractures by Mini-RetromandibularAccess
- J Oral Maxillofac Surg 67:2418-2424, 2009
 Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular
Condyle Fracture of the Mandible - J Oral Maxillofac Surg 68:1578-1584, 2010.
 The post-auricular approach for gap arthroplasty e A clinical investigation-
Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500-505.
130
Surgical anatomy of tmj

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Surgical anatomy of tmj

  • 2. PRESENTATION BY: Dr. Minal Sonare Junior resident 1 st year Department of Oral and maxillofacial surgery 1
  • 3.  Introduction  Basic Anatomy  Relations of Tmj  Movements of Normal Tmj  Associated surgical anatomy  Various surgical approaches and their modifications  Complications  References 2
  • 4. INTRODUCTION: • The tmj is a ginglymoarthrodial joint, a term that is derived from ginglymus, meaning a hinge joint, allowing motion only backward and forward in one plane, and arthrodia, meaning a joint of which permits a gliding motion of the surfaces. • The most important functions of the temporomandibular joint are mastication and speech .
  • 5. • Craniomandibular joint -Articulation between the condylar head of mandible and the anterior part of the glenoid fossa of two temporal bones. • Frequently termed as tmj • Acts like class III lever • Embryology - In contrast to other diarthrodial joints TMJ is last joint to start develop, in about 7th week in utero. It develops from condensation of temporal and condylar blastemata each has its own joint cavity hence there are two spaces in joint .
  • 6. • Bilateral diarthrosis – right & left function together • Only joint in human body to have a rigid endpoint of closure that of the teeth making occlusal contact. • Compound joint • Complex joint • only ellipsoid type of synovial joints with an articular disc and articular surfaces are covered by fibrocartilage instead of hyaline cartilage- can handle better shear forces due to occlusal load. Peculiarity of TMJ :
  • 7. BASIC ANATOMY :COMPONENTS • Mandibular condyle • Articular surfaces of Temporal bone • Articular disc • Capsule • Ligaments • Muscular component
  • 8. The Mandibular Condyle • An ovoid process • It is convex in all directions but wider L-M (15 to 20 mm) than A-P (8 to 10mm). • The medial pole extends sharply inward and is directed more posteriorly. lateral pole is rough, bluntly pointed • Elliptical in shape, long axis angled backward between 15 – 33 to frontal plane • Thus, if the long axes of two condyles are extended medially, they meet at approximately at the basion forming an angle that opens toward the front ranging from 145 to 160 • articular surface lies on its anterosuperior aspect
  • 9. Articular surfaces of Temporal bone • situated on the inferior aspect of temporal squama anterior to tympanic plate. • Articular eminence: transverse bony bar that forms the anterior root of zygoma. • Articular tubercle: this is a small, raised, rough, bony knob on the outer end of the articular eminence. • Preglenoid plane: slightly hollowed, almost horizontal, articular surface
  • 10. Articular disc • Biconcave fibrocartilaginous structure located between • Divides the joint into a larger upper compartment and a smaller lower compartment • Its function is to accommodate a hinging action (lower compartment )as well as the gliding actions(upper compartment) • Shape -Roughly oval, firm, fibrous plate. • Anterior band = 2 mm in thickness, Posterior band = 3 mm thick,Thin in the centre intermediate band of 1 mm thickness. • More posteriorly there is a bilaminar or retrodiscal region. • Superior surface - saddle-shaped ; inferior surface - concave
  • 11. Articular disc • The disc is attached all around the joint capsule except for the strong straps • Anteriorly - attached to a fibrous capsule superiorly and inferiorly. • Posteriorly -the bilaminar region consists of two layers of fibers separated by loose connective tissue. • Upper layer or temporal lamina -composed of elastin and is attached to the postglenoid process. It prevents slipping of the disc while yawning. • Inferior layer - curve down behind the condyle to fuse with the capsule and back of the condylar neck. It prevents excessive rotation of the disc over the condyle.
  • 12. Fibrous Capsule • Thin sleeve of tissue completely surrounding joint. • Extension- the circumference of the cranial articular surface to the neck of the mandible. • The outline – anterolaterally to the articular tubercle, laterally to the lateral rim of the mandibular fossa, posterolaterally to the postglenoid process, posteriorly to the posterior articular ridge, medially to the medial margin of the temporal, anteriorly it is attached to the preglenoid plane • Medially and laterally- blends with the condylodiscal ligaments
  • 13. Fibrous Capsule • Area of relative weakness in the anterior capsular lining becomes a source of possible herniation of intraarticular tissues, and this, in part ,may allow forward displacement of the disk. • Synovial membrane lining the capsule covers all the intra-articular surfaces except the pressure-bearing fibrocartilage. • Four capsular or synovial sulci -the posterior and anterior ends of the upper and lower compartments which changes shape during translatory movements.
  • 14. Ligaments •Three functional ligaments : The collateral ligament The capsular ligament The temporomandibular ligament •Two accessory ligaments: The sphenomandibular ligament The stylomandibular ligament
  • 15. Collateral ligaments • The ligament on each side of the jaw in two distinct layers. • The wide outer or superficial layer is usually fan-shaped and arises from the outer surface of the articular tubercle and most of the posterior part of the zygomatic arch. • The ligamentous fascicles run obliquely downward and backward to be inserted on the back, behind, and below the mandibular neck.
  • 16. Lateral/Temporomandibular ligament • Main stabilizing ligament - thickened capsule - collagen fibers • Course: Down & back attached above to articular eminence , below to outer & post side of neck of condyle, Posterior fibers unite with capsule • Function: limits protraction , inferior distraction ,posterior movement of condyle • Specific length & poor ability to stretch- maintains integrity & limits movement of TMJ (mainly anterior excursion & prevents posterior dislocation – CHECK LIGAMENT • Slippage of condyle:medially prevented by glenoid process , laterally by TM ligament
  • 17. Sphenomandibular ligament • Arises from the angular spine of the sphenoid and petrotympanic fissure. Runs downward and outward.Insert on the lingula of the mandible. • The ligament is related – Laterally - lateral pterygoidmuscle. Posteriorly - auriculotemporal nerve. Anteriorly - maxillary artery. Inferiorly - the inferior alveolar nerve and vessels a lobule of the parotid gland. Medially - medial pterygoid with the chorda tympani nerve and the wall of the pharynx with fat and the pharyngeal veins intervening. • The ligament is pierced by the mylohyoid nerve and vessels. • This ligament is passive during jaw movements
  • 18. Stylomandibular ligament • a specialized dense, local concentration of deep cervical fascia extending from the apex and being adjacent to the anterior aspect of the styloid process and the stylohyoid ligament to the mandible’s angle and posterior border. • This ligament then extends forward as a broad fascial layer covering the inner surface of the medial pterygoid muscle. • The anterior edge - thickened and sharply defined. • Relaxes when the jaws are closed and slackens noticeably when the mouth is opened • This ligament becomes tense only in extreme protrusive movements.
  • 19. Muscular component • The masticatory muscles surrounding the joint are groups of muscles that contract and relax in harmony so that the jaws function properly. • When the muscles are relaxed and flexible and are not under stress, they work in harmony with the other parts of the tmj complex. • The muscles of mastication produce all the movements of the jaw.
  • 21. Vascularisation : Arterial Supply • Branches of external carotid artery • Superficial temporal artery • Deep auricular artery • Anterior tympanic artery • Ascending pharyngeal artery • Maxillary artery • The blood supply to TMJ is only superficial, i.e. There is no blood supply inside the capsule • TMJ takes its nourishment from synovial fluid
  • 22. Vascularisation : Venous Supply •Venous plexus •Maxillary vein •Tranverse facial vein. •Superficial temporal vein.
  • 23. Nerve Supply : •Auriculotemporal •Deep temporal •Massetric nerve
  • 24. Relations of Tmj : Anteriorly • Mandibular notch, lateral pterygoid muscle, masseteric nerve and artery • A careful dissection of 16 intact human cadaveric head specimens revealed the location of the masseteric artery was then determined in relation to 3 points process: 1 ) the anterior-superior aspect of the condylar neck = 10.3 mm 2 ) the most inferior aspect of the articular tubercle = 11.4 mm; 3 ) the inferior aspect of the sigmoid notch = 3 mm.
  • 25. Relations of Tmj : Posteriorly • Parotid gland • Superficial temporal vessels • Auriculotemporal nerve
  • 26. Relations of Tmj : Medio-laterally • Medially -Tympanic plate (separates from ICA) ,Spine of sphenoid,Auriculotemporal & chorda tympani nerve,Middle meningeal artery ,Maxillary artery • Laterally – Skin and fascia Parotid gland Temporal branches of facial nerve
  • 27. Relations of Tmj : Supero-Inferiorly Superiorly – middle cranial fossa middle meningeal vessels Inferiorly – maxillary artery & vein
  • 28. TMJ Movement : • Rotational / hinge movement in first 20-25mm of mouth opening and Translational movement after that when the mouth is excessively opened. • Translatory movement – in the superior part of the joint as the disc and the condyle traverse anteriorly along the inclines of the anterior tubercle to provide an anterior and inferior movement of the mandible. • Hinge movement – the inferior portion of the joint between the head of the condyle and the lower surface of the disc to permit opening of the mandible.
  • 29. TMJ Movement : • Depression Of Mandible- Lateral pterygoid Digrastric Geniohyoid Mylohyoid • Elevation of Mandible - Temporalis Masseter Medial Pterygoids • Protrusion of Mandible - Lateral Pterygoids Medial Pterygoids • Retraction of Mandible- Posterior fibres of Temporalis
  • 30. Lubrication Of The Joint • The synovial fluid comes from two sources: first, from plasma by dialysis, and second, by secretion from type A and B synoviocytes with a volume of no more than 0.05 ml. • • However, contrast radiography studie - the upper compartment could hold approximately 1.2 ml of fluid without undue pressure being created, while the lower has a capacity of approximately 0.5 ml. • It is clear, straw-colored viscous fluid.It diffuses out from the rich capillary network of the synovial membrane. • Contains: Hyaluronic acid which is highly viscous ,May also contain some free cells mostly macrophages. • Functions: • Lubricant for articulating surfaces. • Carry nutrients to the avascular tissue of the joint. • Clear the tissue debris caused by normal wear and tear of the articulating surfaces.
  • 31. 3 1
  • 33. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
  • 34. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
  • 35.  Liebman et al in 1982, described histologically that the layer in which it travels. They reported that it was locked in the fascial layer between temporalis fascia and subdermal fat superficially.  Stuzin et al in 1988, examined the temporal region by cadaver dissection and reported that it lay within the temporoparietal fascia and travels along undersurface of this fascial layer. 35 Temporoal Branch :
  • 36. A straight trajectory A curved trajectory. TEMPORAL BRANCHES OF FACIAL NERVE Ishikawa Y:An anatomical study on the distribution of the temporal branch of the facial nerve. 36
  • 37. Pitanguy, L, A. S. Ramos: The frontal branch of the facial nerve: The importance of its variation in face lifting. Plast. Reconstr. Surg. 38 (1966) 352 MIDDELTON’S LINE 37
  • 38. The new guideline for preservation of the entire temporal branch is drawn with a dashed line. 38 J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
  • 39. Dingman and Grab Ziarah andAtkinson 39
  • 40. Superficial temporal artery Transverse facial artery Maxillary artery 40 7-Mar-17 Atlas of human anatomy – Frank H Netter 6th ed
  • 41. 41 Auriculotemporal nerve Auriculotemporal nerve ARISES FROM POSTERIOR PART OF MANDIBULAR DIVISION OF CN V 41 Atlas of human anatomy – Frank H Netter 6th ed Runs beneath lateral pterygoid muscle. Passes from medial surface of condyle & emerges on to the face behind the TMJ within the superior surface of the parotid gland. Ascends posterior to the superficial temporal vessels, passes over the posterior root of the zygoma, and divides into superficial temporal branches
  • 42. Superficial temporal vein Maxillary vein Retromandibular vein Anterior division Posterior division 42 GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
  • 43. largest ascending branch of the cervical plexus arises from the second and third cervical rami, encircles the posterior border of sternocleidomastoid, perforates the deep fascia and ascends on the muscle beneath platysma On reaching the parotid gland, it divides into anterior and posterior branches 43Greater auricular nerve
  • 44. 44  Temporomandibular joint and its components frequently require exposure for a myriad of procedures.
  • 45. Extraoral approaches 1. Preauricular 2. Endaural 3. Postauricular 4. Coronal 5. Retromandibular 6. Submandibular 7. Rhytidectomy 45 Intraoral approaches 1. Intraoral vestibular – without endoscope with endoscope
  • 46.  Concept given by Teisser & defined by Mitz and Peyronie in 1976.  Continuous fibromuscular layer.  Synonyms:  In scalp – galea aponeurotica  In temporal region – temporoparietal fascia, superficial temporal fascia or suprazygomatic SMAS  Below zygomatic arch – parotideomasseteric fascia 46 Superficial Musculoaponeurotic System
  • 47. Accessibility to the joint Avoiding damage to vital neurovascular structures Aesthetic concerns on visibility of post op scars Technique sensitivity and surgeon’s experience In case of ankylosis, choice of interpositioning material. 47
  • 48. 48Surgical approaches to facial skeleton – Edward Ellis 2nd ed Pre-Auricular Incision :
  • 49. 49 INCISION IS OUTLINED AT THE JUNCTION OF FACIAL SKIN AND HELIX OF THE EAR.
  • 50. • SUPRAFASCIAL PROCEDURE -ROWE NL: SURGERY OF THE TEMPORO-MANDIBULAR JOINT. PROC R SOC MED 65:383, 1972 •SUBFASCIAL PROCEDURE -AL-KAYAT A, BRAMLEY P:AMODIFIED PRE-AURICULAR APPROACH TO THE TEMPOROMANDIBULAR JOINT AND MALAR ARCH. BR J ORAL SURG 17:91, 19 •DEEP SUBFASCIALAPPROACH - MASSIMO POLITI : J ORAL MAXILLOFAC SURG 62:1097-1102, 2004
  • 51. • Incising temporalis fascia • Make an oblique incision (450)parallel to the frontal branch of the facial nerve(2 cm below the malar arch), through the superficial layer of the temporalis fascia above the zygomatic arch. • Begins at the root of zygomatic arch and extends anterosuperiorly towards upper corner of reflected flap 51
  • 52. Coronal view of dissection to the lateral portion of the zygomatic arch and mandibular condyle region. Insert the periosteal elevator beneath the superficial layer of the temporalis fascia and strip the periosteum off the lateral zygomatic arch. 52
  • 53. 53 Blunt dissection below the zygomatic arch Exposed TMJ capsule
  • 54. 54 First incision is through the upper joint space followed by the lower joint incision Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 55. 55
  • 56. Blair’s Inverted Hockey Stick – angulated superiorly Dingman’s Incision- preauricular crease Endaural Incision- lies in ear cartilage Popowich and Crane Incision-question mark shaped incision line goes into the hairline Thoma’s Angulated Incision- angulated at 450 56 Modification of preauricular approach
  • 57. Skin incision is question mark shaped Begins antero-superiorly within the hairline & curves backwards and downwards well posterior until it meets upper ear attachment Incision then follows ear attachment endauraly 57
  • 58. 58
  • 59.  Advantage:  less bleeding  fascial planes can be easily identified  excellent visibility  good cosmetic result 59
  • 60.  Incision is started in the fold at the junction of anterior margin of helix  Carried downwards to upper portion of tragus where it is contained inside the margin of tragus to anterior fold of lobule  It again becomes visible at this point and is carried downwards to lower attachment of ear 60
  • 61. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed 61 FIRST DESCRIBED BY LEMPART AS AN APPROACH TO MASTOID PROCESS FOR SURGICAL IMPROVEMENT OF OTOSCLEROSIS FOR APPROACHING TMJ
  • 62. Incision begins well within the EAM at superior meatal wall The incision is carried carefully through the skin over the tragal cartilage at a 90- degree angle to the most convex part of the tragus itself. The incision is carried superiorly to the uppermost portion of the auricle and then extends in approximately a 45 degree angle into the temporal hairline for about 3 to 4 cm. 62
  • 63. 63
  • 64. Comparison of standard preauricular and endaural surgical approaches Advantages: • Most of the vital structures are in a superficial plane. • Very good access to the joint and also the coronoid process. • Excellent esthetic result with minimal post operative scar Disadvantage: • Esthetic compromise if tragal projection is lost • Risk of possible perichondritis 64
  • 65. ADVANTAGES: • Broad based flap with excellent blood supply • Possibility of residual cartilaginous deformity is less • Damage to CN VII is unlikely 65
  • 67.  Descibed by Alexander & James  Incision is placed in the grove between the helix and post auricular skin  Pre-op considerations described by Walter and Geist: 1. History of normal scar formation 2. Healthy auditory system with no infection 3. No TMJ infection Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed 67
  • 68. 68 3-5cm incision is made parallel & posterior to postauricular flexure Begins at superior aspect of external pinna and extended till the tip of mastoid process Dissection is done through posterior auricular muscle to the level of mastoid fascia
  • 69. Transected auditory canal closure of auditory canal Final closure of the incision. 69
  • 70. ADVANTAGES  Predictability of anatomic exposure  Excellent surgical exposure of the bilaminar zone and the mandibular condyle posteriorly  Cosmetic superiority  Less risk of CN VII injury  Dissection is more rapid 70 DISADVANTAGES  Not advised in patients susceptible to keloid  Infection  Meatal stenosis can occur  Anterior exposure is limited
  • 71.  versatile surgical approach to the upper and middle regions of the facial skeleton, including the zygomatic arch and TMJ.  major advantage of this approach is that most of the surgical scar is hidden within the hairline. 71
  • 73. LAYERS OF THE SCALP BELOW THE SUPERIOR TEMPORAL LINE
  • 74. 74 Incision placement for patients with male pattern hair recession. The incision is stepped posteriorly just above the attachment of the helix of the ear Incision placement for most female patients. The incision is kept approximately 4 cm behind the hairline
  • 75. 75
  • 76. THE INCISION IS THROUGH THE SKIN, SUBCUTANEOUS TISSUE, AND GALEA REVEALING THE SUBGALEAL PLANE OF LOOSE AREOLAR CONNECTIVE TISSUE OVERLYING THE PERICRANIUM 76 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 77. 77
  • 78. The skin incision below the superior temporal line should extend to the depth of the glistening superficial layer of the temporalis fascia, into the subgaleal plane, continuous with the dissection above the superior temporal line. 78Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 79. 79 Along the lateral aspect of the skull, the glistening white temporalis fascia becomes visible where it blends with the pericranium at the superior temporal line. The plane of dissection is just superficial to this thick fascial sheet
  • 80. Near the ear, the flap is dissected inferiorly to the root of the zygomatic arch by incising superficial layer of temporalis fascia The lateral portion of the flap is dissected inferiorly atop the temporalis fascia
  • 81. EXPOSURE OF THE TEMPOROMANDIBULAR JOINT: 81 Access to the TMJ region is gained by dissecting below the zygomatic arch anterior to tragal cartilage. Masseter is detached from the zygomatic arch exposing the sigmoid notch and TMJ capsule. Capsule is then incised exposing the TMJ.
  • 82. CLOSURE: DONE IN LAYERS 82  Closure of TMJ capsule is done followed by closure of temporalis fascia .  Superficial layer of the temporalis fascia, which is incised during the approach, is sutured approximately 1 cm superior to the superior edge of the incised fascia.  Galea is closed as a distinct layer.  Scalp incision is closed.
  • 83. The coronal incision has been modified. The principal difference involves the position of the skin incision – • placed behind the ear. • use of a zigzag incision instead of a straight incision within the hairline.
  • 84. The initial incision is carried through the skin and subcutaneous tissues to the level of the platysma muscle. Surgical approaches to facial skeleton – Edward Ellis 2nd ed Incision usually starts 1.5-2cm inferior to the lower border of mandible. Submandibular Or Risdon Approach
  • 85. Dissection of platysma and exposure of superficial layer of deep cervical fascia 85
  • 86. dissection to the pterygomasseteric muscular sling 86
  • 87. Associated anatomic structures 87Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 88. Dissection is performed through the fascia at the level of the initial skin incision, followed by dissection superiorly to the level of the periosteum of the mandible 88
  • 89. With retraction of the dissected tissues, the inferior border of the mandible is seen. 89Surgical approaches to facial skeleton – Edward Ellis 2nd ed The pterygomasseteric sling is sharply incised with a scalpel along the inferior border
  • 90. 90Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 91. THE MASSETER AND MEDIAL PTERYGOID MUSCLES ARE SUTURED TOGETHER subcutaneous tissues and skin closure is done 91 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 92. 92
  • 93.  exposes the entire ramus from behind the posterior border.  therefore may be useful for procedures involving the area on or near the Condylar neck/head or the ramus itself 93
  • 94.  ADVANTAGES: close proximity to the condylar area  DISADVANTAGES: passing through the parotid gland tissue, thus increasing the risk of facial nerve injury and salivary fistulae. 94
  • 95. 95Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 97. 97  Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 98. 98Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 99. APPROXIMATING PTERYGOMASSETERIC SLING 99 Surgical approaches to facial skeleton – Edward Ellis 2nd ed Closure of parotid capsule
  • 101. 1. Smaller scar as access was limited to 2cm only. 2. Plane of dissection was superficial to SMAS. 3. Risk of Frey’s syndrome, sialocoele and salivary fistula can be eliminated. 4. Surgical site is always perpendicular to fracture site. 5. Integrity of joint is always maintained. 101
  • 102.  Also called as facelift approach.  Variant of retromandibular, transmasseteric - anteroparotid approach 102
  • 103.  When using the rhytidectomy approach, the structures that should be visible in the field include – 1. the corner of the eye, 2. the corner of the mouth, and the lower lip anteriorly, 3. the entire ear and descending hairline, and 2 to 3 cm of hair superior to the posterior hairline, posteriorly 4. the temporal area must also be completely exposed superiorly 103
  • 104. The incision begins approximately 1.5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the hairline. The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna. The incision continues under the earlobe and approximately 3 mm onto the posterior surface of the auricle instead of continuing in the mastoid–ear skin crease. It curves posteriorly toward the hairline and then runs along the hairline, or just inside it, for a few centimeters. 104Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 105. 105Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 106. 106 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 107. 107 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
  • 108. 108
  • 109. 109 Gap arthroplasty for temporomandibular joint ankyloses by transoral approach: A case series Int. J. Oral Maxillofac Surg
  • 110. AD: • better visibility • access to high level fracture using transbuccal trocar. 110
  • 111. Once the capsule has been identified, access to the articular surfaces (superior and inferior joint spaces) can be obtained by a great variety of incisions. 111-
  • 112. ; Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed 112 The lateral ligament, capsule, and periosteum are reflected inferiorly en masse. Discal or posterior attachment are dissected sharply with scissors to the level of the condylar neck.
  • 113. 113 The posterior attachment and disc attachments are then severed sharply at the lateral pole of the condyle from within the developed flap. These tissues are then reflected superiorly from the head of condyle to expose inferior joint space Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
  • 114. The superior joint space is punctured at the level of discocapsular sulcus. A dissection is then carried inferiorly removing the attachment of the capsule to the disc and exposing the inferior joint space. 114 Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
  • 115. 115 Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
  • 116. 116 Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
  • 117. 1. Poor facial scar 2. Infection 3. Wound dehiscence 4. Facial nerve palsy 5. Perichondritis 6. Sialocoele 7. Frey’s syndrome 117
  • 119. 119
  • 120. SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration
  • 121.  MANAGEMENT: 1. Conservative: mildest form is treated by using oral and topical antibiotics. 2. Hematoma of the auricle should be drained properly 3. If there is any sign of pus drainage – C/S followed by broad spectrum IV antibiotics. 4. In resistant cases, continuous drainage and irrigation with antibiotics and steroids solution. 5. In severe cases, aggressive excision of the necrosed cartilage involving overlying subcutaneous tissues and skin should be done. 121
  • 122.  Sialocoeles result in the accumulation of saliva in glandular/periglandular or subcutaneous tissues.  When the accumulated saliva drain through the skin it is termed as salivary fistula. 122
  • 123. MANAGEMENT 1. Small sialocoeles have said to resolve spontaneously by scar formation which seals the salivary flow. 1. Non surgical management:  repeated aspirations and compression dressings  administration of anticholinergics  antisialogogues 123
  • 124. Surgical management: These procedures direct the salivary flow into the mouth or Depresses the salivary secretion 1. Creating a tract intraorally 2. Duct ligation 3. Sectioning of auriculotemporal nerve 4. Surgical excision of fistulous tract 124
  • 125. 125 J Oral Maxillolac Surg49:680-682. 1991 NAMED AFTER DR. LUCIA FREY Frey’s syndrome or gustatory sweating and flushing is characterized by sweating and flushing of the facial skin during meals. The area involved is on the lateral aspect of the face and upper neck, usually around the parotid region.
  • 126.  Techniques to evaluate - Blotting paper method Iodine sublimated paper histogram Treatment: 1. external radiotherapy 2. local or systemic application of anticholinergic drugs Laage-Hellman was the first to apply scopolamine (3% cream) for the treatment of gustatory sweating. 1. interposition of a subcutaneous barrier 2. injection of botulinum toxin in the involved skin 126
  • 127.  Surgical Interposition the use of a barrier between the facial skin and the parotid bed. 127  Botulinum Toxin The injection of botulinum A toxin in the skin involved by gustatory sweating was recently proposed by Drobik and Laskawi. It acts by blocking the exocytosis mechanism of the presynaptic terminal, thereby inhibiting release of acetylcholine.
  • 128.  Know your anatomy properly. - Emphasis on Facial .N relation to fascial layers.  Importance of maintaining proper dissection plane.  Chose the appropriate approach based on the problem.  Be aware of the possible complications from each of the approach.
  • 129. 1. GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed 2. Atlas of human anatomy – Frank H Netter 6th ed 3. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed 4. Oral and maxillofacial trauma – Fonseca 4th ed 5. Surgical approaches to facial skeleton – Edward Ellis 2nd ed 6. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed 7. Salivary gland disorders - Myers 8. An Anatomical Study on the Distribution of the Temporal Branch ofthe Facial Nerve - J. Cranio-Max.-Fac. Surg. 18 (1990) 287-292. 9. A modified pre-auricular approach to the temporomandibular jointand malar arch - British Journal of Oral Surgery 17 (1979-80), 91-103. 10. The surgical anatomy of the mandibular distribution of the facial nerve British Journal of Oral Surgery (1981) 19, 159-l 70. 129
  • 130.  AModified EndauralApproach to the Temporomandibular JointOral Maxillofac Surge 51:33-37,1993.  A new modified endaural approach for access to the temporomandibularjoint British Journal of Oral and Maxillofacial Surgery (2001) 39, 371–373.  The Deep Subfascial Approach to the Temporomandibular Joint - J Oral Maxillofac Surg 62:1097-1102, 2004.  Ankylosis of temporomandibular joint - Dingman  A truly endaural approach to the temporo-mandibular joint - British Journal of Plastic Surgery (1984) 37,65-68.  Transmasseter Approach to Condylar Fractures by Mini-RetromandibularAccess - J Oral Maxillofac Surg 67:2418-2424, 2009  Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular Condyle Fracture of the Mandible - J Oral Maxillofac Surg 68:1578-1584, 2010.  The post-auricular approach for gap arthroplasty e A clinical investigation- Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500-505. 130