Procedures

Intermediate Format
Temporomandibular Joint
Arthroscopy
Objectives
Assess the related terminology and
pathophysiology of the TMJ.
Analyze the diagnostic interventions for a
patient undergoing a _______________.
Plan the intraoperative course for a patient
undergoing_____________.
Assemble supplies, equipment, and
instrumentation needed for the procedure.
Objectives
Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for TMJ
Arthroscopy.
Describe the care of the specimen

Terms and Definitions
Bruxism
Malocclusion
Definition/Purpose of Procedure
Temporomandibular Joint (TMJ)
Disorder occurs when the muscles
used in chewing and the joints of
the jaw fail to work in
combination with each other.


A & P : TMJ
Pathophysiology
Causes:
Bruxism, Malocclusion, Arthritis,
Trauma


Pathophysiology
Signs & Symptoms
Pain, clicking, limited range-of-
motion, spasms, asymmetry
Diagnosis
Linear CT and MRI
Treatment
5-10 % dx w/TMJ Dysfunction fail to have relief
of medical tx, and require surgery
Antiinflammatories, soft diet, hot compresses,
muscle relaxants
>2 weeks: intraoral occlusion splints, med tx
Recurrent or chronic: permanent dental correction

Surgical Intervention:
Special Considerations

Patient Factors
Outpatient
H& P, Blood chemistries, CBC, PT, PTT, U/A,
serum HCG, Chest x-ray or ECG as appropriate
Room Set-up
X-rays in room

Surgical Intervention: Positioning
Position during procedure
Supine w/head donut pillow, tuck arms to side
Supplies and equipment
Arm sleds, headring pillow
Special considerations: high risk areas
Elbowsulnar nerves
Prep
Shave preauricular area
Cotton to ears to prevent pooling of povidone-iodine & caution
w/eyes; entire facial area prepped from hairline, down to shoulder,
and laterally to include mouth and chin
Surgical Intervention: Special
Considerations/Incision

Special considerations
Nasal intubation
Prophylactic antibiotics & steriods
State/Describe incision
Small stab incision w/# 11 before trocar is
introduced at superior joint space
Surgical Intervention: Supplies
General: basic pack drape and split head sheet, gowns &
gloves, towels, basin set, prep set, sterile adhesive wound
drape, irrigation pouch, skin marker, raytex,
Specific
Suture & Blades (# 11)
Medications on field (name & purpose)
Catheters & Drains: n/a
Drapes: head turban for initial drape; pad pt forehead with a
folded towel; plastic adhesive wound drape to cover ET tube and
mouth; split sheet and large sheet for body drape, (laser: 4 wet
towels around pts face; moistened cotton in external auditory
canals, irrigation collection pouch at base of ear and TMJ)
Surgical Intervention: Supplies contd
2 60 mL syringes
4 10 mL syringes
1 1-mL syringe
Needles: 18 g, 21 g, 25 g
Skin stapler
Eye pads
Sterile water and saline
1000 mL Lactated Ringers for irrigation
30 in extension tubing
Stopcock
Surgical Intervention: Instruments
General: suction, Lactated Ringers IV bag for irrigation,
marking pen
Specific
TMJ instrument set
0 degree arthroscope
30-degree arthroscope
70-degree arthroscope
Cannulas
Sharp & dull obturators
Light cord, camera & cord, small joint rotary shaver
Surgical Intervention: Equipment
General: suction system
Specific
Monitor/light source/camera tower, shaver control unit,
IV pole for irrigant
Fluid infusion system
Bipolar ESU
Holmium laser
Surgical Intervention: Procedure Steps
Irrigation solution is injected into the joint space to distend
the capsule
LR solution is preloaded in syringe w/needle attached.
After small stab incision is placed, surgeon inserts a sheath
w/sharp obturator into superior joint space. After space is
entered, the sharp is replaced with a dull obturator to
further direct the sheath into the joint without damaging
the intraarticular tissue or adjacent neurovascular
structures.
#11 blade with # 7 handle will be ready
Trocar/cannula is preassembled. Expect trocor to be returned. Be
prepared to assist with connections of video/light cord connections.


Surgical Intervention: Procedure Steps
Irrigation is infused into the joint
LR solution is connected to the cannua via extension
tubing
Joint is examined
Prepare to operate remote control for still photos
If functional surgery is needed, a second stab wound is
made
Pass skin knife. Prepare additional equipment (probe, shaver,
grasper)
Final visual inspection is performed
Additional photos may be taken
Surgical Intervention: Procedure Steps
Cannuale are removed and excess fluid
removed
Prepare for closure; count
Wound is closed and dressing placed
Pass suture; prepare dressings, reorganize
equipment & supplies if procedure is bilateral
Steps may be repeated contralaterally
Repeat steps
Counts
Initial: sponges and sharps
First closing
Final closing
Sponges
Sharps
Specimen & Care
Identified as n/a or as specified (eg
chondromalacia)
Handled: routine, etc.
Postop Considerations
Immediate
ROM of jaw limited
Suction and Emergency airway supplies readily
available; Elevate HOB 30 degrees
Ice for pain and swelling
Liquid or soft diet for several days
Prognosis: goodmay recur if behaviors not
resolved; PT may begin in 24-48 hrs post-op.
Complications: hemorrhage, infection, recurrence
Joint damage, destruction of middle ear ossicles, perforation into
middle cranial fossa, injury to auriculotemporal nerve
Resources
www.healthscout.com
STST pp. 646-647, Procedure 18-7
www.dentaljournal.com/article 6
Rodau; Baker-Gill, Levin; Arthroscopic
Temporomandibular Joint Surgery, AORN
Journal Nov 1993, 58: 5.