**6.1 Indications for arthroscopy**

Indications for arthroscopy are radiological bone changes in TMJ characteristic to osteoarthritis with disc displacement or deformity and non effectiveness of conservative treatment with NSAIDs, intraoral splints or arthrocentesis. In practice, the decision to operate and the choice of the method seems to be a matter of the individual surgeon´s training, experience, and attitude toward the surgical management of TMJ disorders. Involvement of the TMJ in patients with rheumatoid arthritis or other connective tissue diseases is rather common and arthroscopy with simultaneous biopsy is indicated in these situations. Posttraumatic complaints may also be an indication for arthroscopy. Arthroscopy is contraindicated in case of acute arthritis. In these situations as large medial osteophyts on the condyle, large central cartilaginous perforations, fibrous, fibro-osseous, osseous ankylosis are better to handle *via* open reduction. Arthocentesis is considered as an intervening treatment modality between nonsurgical treatment and arthroscopic surgery. All cases for arthroscopy are usually classified as advanced Wilkes (1989) stages IV and V, in rare cases stage III (Table 1).

### **6.2 Technique for arthroscopy**

Arthroscopy is performed under nasotracheal general anaesthesia which makes possible to manipulate the mandible during the operation. First the zygomatic arch and the condyle are palpated. The condyle is then forced in anterior position by the assistant and the

Fig. 8. Sagittal view of the MRI in a patient with internal derangement of the left TMJ. Anterior disc displacement (arrow), destruction of the disc. Changes of bone structures,

Indications for arthroscopy are radiological bone changes in TMJ characteristic to osteoarthritis with disc displacement or deformity and non effectiveness of conservative treatment with NSAIDs, intraoral splints or arthrocentesis. In practice, the decision to operate and the choice of the method seems to be a matter of the individual surgeon´s training, experience, and attitude toward the surgical management of TMJ disorders. Involvement of the TMJ in patients with rheumatoid arthritis or other connective tissue diseases is rather common and arthroscopy with simultaneous biopsy is indicated in these situations. Posttraumatic complaints may also be an indication for arthroscopy. Arthroscopy is contraindicated in case of acute arthritis. In these situations as large medial osteophyts on the condyle, large central cartilaginous perforations, fibrous, fibro-osseous, osseous ankylosis are better to handle *via* open reduction. Arthocentesis is considered as an intervening treatment modality between nonsurgical treatment and arthroscopic surgery. All cases for arthroscopy are usually classified as advanced Wilkes (1989) stages IV and V, in

Arthroscopy is performed under nasotracheal general anaesthesia which makes possible to manipulate the mandible during the operation. First the zygomatic arch and the condyle are palpated. The condyle is then forced in anterior position by the assistant and the

effusion in the anterior recess.

**6.1 Indications for arthroscopy** 

rare cases stage III (Table 1).

**6.2 Technique for arthroscopy** 

**6. Temporomandibular joint arthroscopy** 

preauricular concavity is formed in the skin, marking a point for the injection. Usually arthroscope KARL STORZ GmbH & Co.KG is used. Although various arthroscopic approaches to the TMJ have been described, the one most commonly used is the posterolateral approach to the upper joint space. After the condylar head of the TMJ has been determined , a marking line and puncture points are made on the skin surface (Fig. 9).

Fig. 9. A marking line and the puncture points on the skin surface for TMJ arthroscopy

The puncture site is located by manipulating the mandible anterio-inferiorly. For distension of the superior compartement and in order to avoid iatrogenic damage to the cartilaginous surfaces during introduction of the trocar, 1% lidocain solution 2,0 mL is inserted. The needle is aimed in a medial and slightly anteriosuperior direction until the contact with the glenoid fossa is achieved. The posterior recess of the superior joint space is reached when there is a backflow into the syringe of the solution injected into the joint space (Fig.10).

Fig. 10. Distension of the superior compartment of the right temporomandibular joint with 2% lidocaine solution.

Temporomandibular Joint Arthroscopy 15

arthroscopy has been completed, either forceps, palpation hook or blunt probe are used to cut fibres, mainly fibers of the pterygoid muscle anterior to the disc, in order to reduce pull in the anterior direction and facilitate repositioning of the disc. Cutting of adhesions facilitate repositioning of the disc. During arthroscopy a sweeping procedure between the disc and fossa release the adhesions and fibrillations increasing the mobility in the joint. Release of the adhesions and fibrillations of the superior suface of the disc and shaving the surface of articular fossa in the upper joint compartment are performed with the aid of a blunt obturator or hook and with grasping forceps, scissors or double-edged knife. Removal of the superficial layer of cortical bone induces capillar bleeding stimulating formation of fibrocartilage on bone. Quite often a displaced disc may be found during arthroscopy. Surgical procedure is completed by irrigating the joint space to remove small tissue fragments. The outflowing fluid is collected and may be retained for diagnostic purposes. Arthroscopic lysis and lavage includs also a lateral release of the upper joint compartment performed with the aid of the blunt obturator or hook.Thus the locked disc could be mobilized sufficiently. Clinical, radiographic and arthroscopic findings in patients who

underwent arthroscopy are given in Table 2 (Leibur et al. 2010).

**bility 23 79 Bone cyst / Subchondral** 

**abn Radiographic findings Sum %** 

**Pain 25 86 Flattening 10 34 Adhesions 29 100** 

**Closed lock 5 17 Erosions 20 69 Fibrillations 22 76** 

**lock 5 17 Reduced space 10 34 Synovitis 9 31** 

**condyle Osteophyts 4 5 <sup>14</sup>**

Sum = total number of patients with findings; % abn = percentage of individuals with abnormal

Arthroscopic findings are as follows: irregularities of joint surfaces, foldings and synovitis – hyperaemia of the inner wall, localising also in the posterior part of the disc, intra-articular fibrous adhesions, intracapsular adhesions, fibrillations of superior surface of the disc and arthrotic lesions of temporal cartilage, pseudowalls, foreign bodies - chondromatosis (Fig.

Table 2. Clinical, radiographic and arthroscopic findings in patients who underwent

**Deviation 4 14 Sclerosis 8 27 Eburneation** 

**Hypomobilityof** 

**pseudocycts 9 31 Chondro-**

**abn**

**17** 

**Arthroscopic findings** 

**Sum %** 

**matosis 5 17** 

**of fossa 15 52** 

**disc 23 23** 

**Displaced** 

**abn** 

**Signs and** 

**Hypomo-**

**Intermittent** 

findings.

arthroscopy (N=29).

12, 13, 14, 15).

**symptoms Sum %** 

Through the small skin incision 0,75 – 1,0 cm from the center of the *tragus* at the injection site the lateral capsule is punctured with a sharp trocar in an arthroscopic sheath inserted in the same direction as the previous injection needle. The sharp trocar is exchanged for a blunt one and the arhroscopic sheath is advanced further into the upper joint space. Puncture with arthroscope sheath (trocar) with a blunt obturator inserted into upper posterior recess is performed angling it medially upward ~ 2,5 cm. Another skin incision is made ~ 0,75 cm from the first skin incision in anterolateral direction for outflow cannula to be inserted into the upper joint anterior recess.

Following insertion of the trocar (diameter 1,8 mm, length 4 cm) into the joint space, blunt obturator is removed and forward-oblique telescope 30º (HOPKINS®), diameter 1,9 mm, length 6,5 cm, fiber optic light transmission incorporated is inserted (Fig. 11).

Fig. 11. Forward - oblique telescope 30° (HOPKINS®) fiber optic light transmission incorporated and outflow cannula are inserted into the right upper temporomandibular joint space.

Initial recognition of anatomical structures as the superior surface of the disc, articular fossa, and internal aspects of the posterior and medial capsule is performed. The fluid level in the arthroscope sheath should move with the jaw, confirming that the sheath is correctly positioned in the joint upper space.The upper joint compartment is examined from the posterior pouch *via* the intermediate zone to the anterior pouch. Disc may give the impression of being obstructed against the arthrotic surface of the temporal cartilage. The anterior part of the disc surface looks usually smooth and collagen fibres could clearly seen. The condylar cartilage is normally smooth, but in case of pathology e.g. in osteoarthritis where irregularities of the surface as erosions, osteophyts can be seen. Sever arthrotic changes of both fossa cartilage and disc may also observed. Adhesions between the disc and glenoid fossa are quite common. In rare cases the arthrotic or inflammatory changes are found in the anterior recess. Upper compartment is swept clear under constant irrigation with isotonic saline solution. This manipulation allow translation of the disc along the eminence, allowing the condyle to complete its natural path. After the diagnostic

Through the small skin incision 0,75 – 1,0 cm from the center of the *tragus* at the injection site the lateral capsule is punctured with a sharp trocar in an arthroscopic sheath inserted in the same direction as the previous injection needle. The sharp trocar is exchanged for a blunt one and the arhroscopic sheath is advanced further into the upper joint space. Puncture with arthroscope sheath (trocar) with a blunt obturator inserted into upper posterior recess is performed angling it medially upward ~ 2,5 cm. Another skin incision is made ~ 0,75 cm from the first skin incision in anterolateral direction for outflow cannula to be inserted into

Following insertion of the trocar (diameter 1,8 mm, length 4 cm) into the joint space, blunt obturator is removed and forward-oblique telescope 30º (HOPKINS®), diameter 1,9 mm,

length 6,5 cm, fiber optic light transmission incorporated is inserted (Fig. 11).

Fig. 11. Forward - oblique telescope 30° (HOPKINS®) fiber optic light transmission incorporated and outflow cannula are inserted into the right upper temporomandibular

Initial recognition of anatomical structures as the superior surface of the disc, articular fossa, and internal aspects of the posterior and medial capsule is performed. The fluid level in the arthroscope sheath should move with the jaw, confirming that the sheath is correctly positioned in the joint upper space.The upper joint compartment is examined from the posterior pouch *via* the intermediate zone to the anterior pouch. Disc may give the impression of being obstructed against the arthrotic surface of the temporal cartilage. The anterior part of the disc surface looks usually smooth and collagen fibres could clearly seen. The condylar cartilage is normally smooth, but in case of pathology e.g. in osteoarthritis where irregularities of the surface as erosions, osteophyts can be seen. Sever arthrotic changes of both fossa cartilage and disc may also observed. Adhesions between the disc and glenoid fossa are quite common. In rare cases the arthrotic or inflammatory changes are found in the anterior recess. Upper compartment is swept clear under constant irrigation with isotonic saline solution. This manipulation allow translation of the disc along the eminence, allowing the condyle to complete its natural path. After the diagnostic

the upper joint anterior recess.

joint space.

arthroscopy has been completed, either forceps, palpation hook or blunt probe are used to cut fibres, mainly fibers of the pterygoid muscle anterior to the disc, in order to reduce pull in the anterior direction and facilitate repositioning of the disc. Cutting of adhesions facilitate repositioning of the disc. During arthroscopy a sweeping procedure between the disc and fossa release the adhesions and fibrillations increasing the mobility in the joint. Release of the adhesions and fibrillations of the superior suface of the disc and shaving the surface of articular fossa in the upper joint compartment are performed with the aid of a blunt obturator or hook and with grasping forceps, scissors or double-edged knife. Removal of the superficial layer of cortical bone induces capillar bleeding stimulating formation of fibrocartilage on bone. Quite often a displaced disc may be found during arthroscopy. Surgical procedure is completed by irrigating the joint space to remove small tissue fragments. The outflowing fluid is collected and may be retained for diagnostic purposes. Arthroscopic lysis and lavage includs also a lateral release of the upper joint compartment performed with the aid of the blunt obturator or hook.Thus the locked disc could be mobilized sufficiently. Clinical, radiographic and arthroscopic findings in patients who underwent arthroscopy are given in Table 2 (Leibur et al. 2010).


Sum = total number of patients with findings; % abn = percentage of individuals with abnormal findings.

Table 2. Clinical, radiographic and arthroscopic findings in patients who underwent arthroscopy (N=29).

Arthroscopic findings are as follows: irregularities of joint surfaces, foldings and synovitis – hyperaemia of the inner wall, localising also in the posterior part of the disc, intra-articular fibrous adhesions, intracapsular adhesions, fibrillations of superior surface of the disc and arthrotic lesions of temporal cartilage, pseudowalls, foreign bodies - chondromatosis (Fig. 12, 13, 14, 15).

Temporomandibular Joint Arthroscopy 17

Fig. 14. Posterior recess of the superior compartment of the right TMJ. Fibrous adhesions, fibrillations and smooth fibres seen clearly. Synovial inflammation is obvious, localizing in

Fig. 15. Posterior recess of the superior compartment of the left TMJ. Debris on the posterior glenoid fossa wall can be seen. Fibrillations, adhesions and increased vascularization in the

the posterior part of the disc.

posterior capsular wall.

Fig. 12. Posterior recess of the superior compartment of the right TMJ. Fibrillations and pronounced adhesions with appearance irregularities of condylar surface, hyperaemia in the posterior capsular wall.

Fig. 13. Posterior recess of the superior compartment of the left TMJ. Eburneation of glenoid fossa, adhesions and fibrillations with "crab meat" appearance, mild granulations, irregularities of condylar surface, hyperaemia of the posterior attachment can be determined.

Fig. 12. Posterior recess of the superior compartment of the right TMJ. Fibrillations and pronounced adhesions with appearance irregularities of condylar surface, hyperaemia in the

Fig. 13. Posterior recess of the superior compartment of the left TMJ. Eburneation of glenoid

fossa, adhesions and fibrillations with "crab meat" appearance, mild granulations, irregularities of condylar surface, hyperaemia of the posterior attachment can be

.

.

determined.

posterior capsular wall.

Fig. 14. Posterior recess of the superior compartment of the right TMJ. Fibrous adhesions, fibrillations and smooth fibres seen clearly. Synovial inflammation is obvious, localizing in the posterior part of the disc.

Fig. 15. Posterior recess of the superior compartment of the left TMJ. Debris on the posterior glenoid fossa wall can be seen. Fibrillations, adhesions and increased vascularization in the posterior capsular wall.

Temporomandibular Joint Arthroscopy 19

maintained improvement in maximal interincisal opening (MIO) and visual analogue scale (VAS) is also observed over the 5 years period of time (Fig. 16, 17), (Leibur et al. 2010).

Fig. 16. Graphical representation of VAS values (median) before treatment and after 6

Fig. 17. Graphical representation of MIO values (median) before treatment and after 6

TMJ arthroscopy is especially useful when the disc has not yet been deformed. Superior joint compartment adhesions and disc immobility can be treated during arthroscopic

months and 5 years treatment in patients (n = 29).

months and 5 years after treatment in patients (n = 29).

The patients are to be followed up after 6 months and approximayely 5 years after the operation. Intravenous antibiotics at the beginning of the procedure is recommended. Concepts of irrigation are to maintain the capsule distended through the procedure. Continuous irrigation constantly cleanses a joint debris and blood, increases mobility, reliefing symptoms. It is also important to use of adjunctive therapy postoperatively to obtain maximum success with arthroscopic surgery e.g*.* physical therapy especially in case of haemorrage, as it may prolong healing time. A pressure dressing during the first couple of hours after the operation is recommended.

#### **6.3 Summary of arthroscopic findings**

A number of arthroscopic findings as fibrous adherences mainly between the disc and fossa, fibrillations with "crab meat" appearance, mild granulations, irregularities of condylar surface, foreign bodies, increased vascularisation are to be found. Synovitis in the upper joint space of the TMJ has been observed during arthroscopy and this inflamed synovium may cause pain. The alterations in the constituents of the synovial fluid affect lubrication of the joint causing stickness and decreased mobility. Synovial chondromatosis has been found in the joint space (Mercuri, 2008; Leibur *et a*l. 2010; González-Pérez et al., 2011). Synovial chondromatosis of the TMJ in both the superior and inferior joint compartments have found due to osteoarthritis during long period ~ 10 years (Sato et al., 2002).

#### **6.4 Possible complications**

Intra- and postoperative complications for arthroscopy are rare. Bleeding may be from branches of the temporal vein during puncture. Extravasation of irrigation fluid into surrounding tissues may be occur sometimes due to leakage of the irrigating fluid into the surrounding tissues caused by accidental perforation of the TMJ capsule. This situation is easily controled if the surgeon always check the out-flow from out-flow cannula. From postoperative complications a few cases with otologic complications and nerve damage have been reported (Appelbaum et al.,1988; McCain et al., 1992). Injurie of superficial branches of facial nerve resulting to paraesthesia in the preauricular region was observed in two cases. These symptoms disappeared during one month (Leibur et al. 2010).

### **7. Analysis of clinical data and results**

It has been shown that during arthroscopy several inflammatory and pain mediators causing destructive changes, foreign bodies as grains of chondromatosis are washed out elicitating joint noises (Shibuya et al., 2002; González-Pérez et al., 2011). For the patients with episodic signs and symptoms a noninvasive conservative approach is indicated (Wilkies stages I-III). Procedures currently used for the TMJ derangements as osteoarthritis/arthrosis (Wilkies stages IV and V) are: arthrocentesis, arthroscopy, arthrotomy or TMJ replacement. From arthroscopic findings fibrillation seemed to be the most common ~76% (Dimitrouli*s,* 2002). Arthroscopic lysis and lavage has been an effective treatment for TMJ disorders refractory to nonsurgical treatments (Ohnuki et al., 2003; Sanroman, 2004; Politi et al., 2007). An evaluation following temporomandibular joint arthroscopic surgery with lysis and lavage after 2 to 10,8 years treatment showed that arthroscopic surgery of the temporomandibular joint is successful in the long term for patients in case of osteoarthritis and painful motion (Sorel & Piecuch, 2000). Assessment of symptoms reported by the patient as well as of objective signs noted on clinical examination confirms resolution of pain on movement and increased vertical opening. A significant and

The patients are to be followed up after 6 months and approximayely 5 years after the operation. Intravenous antibiotics at the beginning of the procedure is recommended. Concepts of irrigation are to maintain the capsule distended through the procedure. Continuous irrigation constantly cleanses a joint debris and blood, increases mobility, reliefing symptoms. It is also important to use of adjunctive therapy postoperatively to obtain maximum success with arthroscopic surgery e.g*.* physical therapy especially in case of haemorrage, as it may prolong healing time. A pressure dressing during the first couple

A number of arthroscopic findings as fibrous adherences mainly between the disc and fossa, fibrillations with "crab meat" appearance, mild granulations, irregularities of condylar surface, foreign bodies, increased vascularisation are to be found. Synovitis in the upper joint space of the TMJ has been observed during arthroscopy and this inflamed synovium may cause pain. The alterations in the constituents of the synovial fluid affect lubrication of the joint causing stickness and decreased mobility. Synovial chondromatosis has been found in the joint space (Mercuri, 2008; Leibur *et a*l. 2010; González-Pérez et al., 2011). Synovial chondromatosis of the TMJ in both the superior and inferior joint compartments have found

Intra- and postoperative complications for arthroscopy are rare. Bleeding may be from branches of the temporal vein during puncture. Extravasation of irrigation fluid into surrounding tissues may be occur sometimes due to leakage of the irrigating fluid into the surrounding tissues caused by accidental perforation of the TMJ capsule. This situation is easily controled if the surgeon always check the out-flow from out-flow cannula. From postoperative complications a few cases with otologic complications and nerve damage have been reported (Appelbaum et al.,1988; McCain et al., 1992). Injurie of superficial branches of facial nerve resulting to paraesthesia in the preauricular region was observed in

It has been shown that during arthroscopy several inflammatory and pain mediators causing destructive changes, foreign bodies as grains of chondromatosis are washed out elicitating joint noises (Shibuya et al., 2002; González-Pérez et al., 2011). For the patients with episodic signs and symptoms a noninvasive conservative approach is indicated (Wilkies stages I-III). Procedures currently used for the TMJ derangements as osteoarthritis/arthrosis (Wilkies stages IV and V) are: arthrocentesis, arthroscopy, arthrotomy or TMJ replacement. From arthroscopic findings fibrillation seemed to be the most common ~76% (Dimitrouli*s,* 2002). Arthroscopic lysis and lavage has been an effective treatment for TMJ disorders refractory to nonsurgical treatments (Ohnuki et al., 2003; Sanroman, 2004; Politi et al., 2007). An evaluation following temporomandibular joint arthroscopic surgery with lysis and lavage after 2 to 10,8 years treatment showed that arthroscopic surgery of the temporomandibular joint is successful in the long term for patients in case of osteoarthritis and painful motion (Sorel & Piecuch, 2000). Assessment of symptoms reported by the patient as well as of objective signs noted on clinical examination confirms resolution of pain on movement and increased vertical opening. A significant and

due to osteoarthritis during long period ~ 10 years (Sato et al., 2002).

two cases. These symptoms disappeared during one month (Leibur et al. 2010).

of hours after the operation is recommended.

**7. Analysis of clinical data and results** 

**6.3 Summary of arthroscopic findings** 

**6.4 Possible complications** 

maintained improvement in maximal interincisal opening (MIO) and visual analogue scale (VAS) is also observed over the 5 years period of time (Fig. 16, 17), (Leibur et al. 2010).

Fig. 16. Graphical representation of VAS values (median) before treatment and after 6 months and 5 years treatment in patients (n = 29).

Fig. 17. Graphical representation of MIO values (median) before treatment and after 6 months and 5 years after treatment in patients (n = 29).

TMJ arthroscopy is especially useful when the disc has not yet been deformed. Superior joint compartment adhesions and disc immobility can be treated during arthroscopic

Temporomandibular Joint Arthroscopy 21

bite and rethrognathia may occur ( Emshoff et al., 2003; Emshoff, 2005; Hamada et al., 2005). During arthroscopic surgery nodules of TMJ synovial chondromatosis are able to pass through the cannula by lavage with saline solution (Shibuy*a* et al., 2002). Based on the present findings, it follows that a displaced disc, by itself, is of only limited significance. This is not surprising because the majority of individuals with derangement of the TMJ are asymptomatic (Holmlund et al., 2001; Hamada et al., 2005). The intriguing question that remains is why lavage and lysis of adhesions or high-pressure irrigation of the upper joint space should be therapeutic. The answer is, that during this procedure several inflammatory mediators available in the synovial fluid as prostaglandins (K.I. Murakam*i* et al., 1998), cytokines (Kardel et al., 2003; Voog et al., 2003b), serotonin as pain mediator (Voog et al., 2000) etc. are washed out. In episodes of closed lock , the limitation in condylar movement probably originates from changes in the upper compartment that restrict the sliding motion of the disc. This course of events may explain the efficacy of lysis and lavage of only this joint space, as this manipulation allows translation of the disc along the eminence, allowing the condyle to complete its natural path. The data in the literature have stated that the most frequent disc displacements were anterior and anteromedial *(* Sorel & Piecuch, 2000). In episodes of closed lock , the limitation in condylar movement probably originates from changes in the upper compartment that restrict the sliding motion of the disc. The data in the literature have stated that the most frequent disc displacements were anterior and anteromedial. Using MRI pre- and postoperatively revealed that disc position remained anteriorly without reduction, disc mobility increased and deformity of the discs progressed after arthroscopic surgery (Ohnuki et al. 2003). Improvement in joint symptoms and function is not attributed so much as to the restoration of disc position as to possible release of the lateral capsular fibrosis during arthroscopy (Moses & Lo,1992; Sorel & Piecuch, 2000).

There is still a group of patients whom an arthrotomy and disc surgery are necessary e.g. to treat painful clicking in patients with anteriorly displaced, nonreducing discs and limited mouth opening, irreparable disc perforation or if it is misshaped , shortened, rigid (Laskin, 2006). Large medial osteophyts on the condyle are very difficult to shave arthroscopically, and in these situations they are better to handle *via* arthrotomy. Large central cartilaginous perforations may need an arthrotomy and possibly discectomy, although there are data about healing of disc perforations as the bilaminar zone undergoes metaplastic changes forming pseudodisc (Moses & Lo, 1992). The importance of disc position and shape is emphasized by many authors (Ohnuki et al., 2003; Politi et al., 2007). As a result, open joint procedures are developed to reposition the displaced disc (Holmlund et al., 2001; González - Garcia et al., 2008). Direct comparison of the clinical results are achieved in patients following arthroscopic surgery with a group of patients who underwent open surgery. The postoperative follow-up period ranged 5 to 6 years and 9 months. These results following open and arthroscopic surgery measured with the Jaw Pain and Function Questionnaire a self rating scale, originally published by Clark et al., 1989; and differentiated by Wilkes´(1989) stages. No significant difference was noted when comparing the groups 5 years postoperatively (Undt et al., 2006).

Clinical success of arthroscopy is based on several factors. Lysis and lavage remove intraarticular inflammatory and pain mediators. The release of fibrillations and adhearences

**8. Arthroscopy vs. arthrotomy** 

**9. Summary** 

procedure, leading to resolution of symptoms and return of joint function (Leibur et al. 2010). The adhesions may cause retention of the disc in its anteriorly displaced position, which may explain the failure to respond to conservative treatment.

An adherence of the disc to the fossa may be caused by an alteration of the normal lubrication of the joint as a result of intermittent joint overloading, with secondary activation of oxidative species and degradation of hyaluronic acid. Anchored Disc Phenomen could be one of the first clinical symptoms observed in the chain events that would end in a more severe internal derangement (Sorel & Piecuch, 2000; Krug et al. 2004). Long-term results of TMJ arthroscopy have been analysed demonstrating a high accuracy for adhesions, fibrillations and degenerative changes of the bone structures. The adhesions may cause retention of the disc in its anteriorly displaced position, which may explain the failing response to conservative treatment. It has been shown that during this procedure several inflammatory and pain mediators causing destructive changes and chondromatosis are washed out elicitating joint noises (Emshoff et al., 2003; Voog et al., 2003b; Leibur et al., 2010). It is important to select the procedure with the highest probability of success and least morbidity. For the patients with episodic signs and symptoms a noninvasive , conservative approach is indicated (Wilkies stages I-III). Procedures currently used for the TMJ derangements as osteoarthritis/arthrosis (Wilkies stages IV and V) are: arthrocentesis (Sanroman, 2004), arthroscopy, arthrotomy or TMJ replacement (McCain et al.,1992; Smolka & Iizuka, 2005). Pain and hypomobility seems to be a part of a wide spectrum of symptoms appearing in the context of chronic dysfunction of the TMJ. Some authors have reported that the major symptom has been closed lock phenomenon (Dimitroulis, 2002; Sanroman, 2004). From arthroscopic findings *(*Dimitroulis 2002) fibrillation seemed to be the most common - 76%. In other study (Leibur et al. 2010) closed lock was found in 17,2 % and fibrillations in 75,8 % of cases. Several authors (K.Murakami et al., 2000; Sorel & Piecuch, 2000) performed long-term evaluation following temporomandibular joint arthroscopic surgery with lysis and lavage covering 10 years. On the bases of assessment of symptoms reported by the patients as well as objective signs noted on clinical examination confirmed resolution of pain on movement and increased maximal interincisial opening.. In a later study also lysis and lavage improved translation of the joint, decreased or eliminated pain. The chief presenting complaint for most patients (86,2%) was pain preoperatively. A significant maintained decrease in VAS score was achieved after 6 months and also after 5 years follow-up. A significant and maintained improvement in MIO was also observed over the same period of time (Leibur et al., 2010).The results are comparable to those reported in the other papers (Sorel and Piecuch, 2000; Smolka and Iizuka, 2005). It is important to take into account that the sympathetic and sensory nerve fibres within the temporomandibular joint are located in the anterior recess and the retrodiscal tissue of the upper compartment. Anterior disc release may reduce the number of these nerve fibres in arthroscopic procedures, thus influencing pain dynamics. The advantages of arthroscopy compared with open joint surgery using the Jaw Pain and Function Questionnaire are that arthroscopic surgery is less invasive and associated with lower morbidity (Undt et al., 2006). No statistical differences were also observed between arthroscopic lysis and lavage and operative arthroscopy in relation to postoperative pain or MIO at any stage of the follow-up period (Gonzalez – Garcia et al., 2008). The limitation in condylar movement probably originates from changes in the upper compartement that restricts the sliding motion of the disc. Arthroscopy improved the condylar movement. Arthroscopic lysis and lavage has been found effective in 84% of patients in case of osteoarthritis of TMJ (Dimitroulis, 2005). Multiple adhesions also develop skeletal changes, with a shortened ramus. If the condition develops rapidly enough, open

procedure, leading to resolution of symptoms and return of joint function (Leibur et al. 2010). The adhesions may cause retention of the disc in its anteriorly displaced position,

An adherence of the disc to the fossa may be caused by an alteration of the normal lubrication of the joint as a result of intermittent joint overloading, with secondary activation of oxidative species and degradation of hyaluronic acid. Anchored Disc Phenomen could be one of the first clinical symptoms observed in the chain events that would end in a more severe internal derangement (Sorel & Piecuch, 2000; Krug et al. 2004). Long-term results of TMJ arthroscopy have been analysed demonstrating a high accuracy for adhesions, fibrillations and degenerative changes of the bone structures. The adhesions may cause retention of the disc in its anteriorly displaced position, which may explain the failing response to conservative treatment. It has been shown that during this procedure several inflammatory and pain mediators causing destructive changes and chondromatosis are washed out elicitating joint noises (Emshoff et al., 2003; Voog et al., 2003b; Leibur et al., 2010). It is important to select the procedure with the highest probability of success and least morbidity. For the patients with episodic signs and symptoms a noninvasive , conservative approach is indicated (Wilkies stages I-III). Procedures currently used for the TMJ derangements as osteoarthritis/arthrosis (Wilkies stages IV and V) are: arthrocentesis (Sanroman, 2004), arthroscopy, arthrotomy or TMJ replacement (McCain et al.,1992; Smolka & Iizuka, 2005). Pain and hypomobility seems to be a part of a wide spectrum of symptoms appearing in the context of chronic dysfunction of the TMJ. Some authors have reported that the major symptom has been closed lock phenomenon (Dimitroulis, 2002; Sanroman, 2004). From arthroscopic findings *(*Dimitroulis 2002) fibrillation seemed to be the most common - 76%. In other study (Leibur et al. 2010) closed lock was found in 17,2 % and fibrillations in 75,8 % of cases. Several authors (K.Murakami et al., 2000; Sorel & Piecuch, 2000) performed long-term evaluation following temporomandibular joint arthroscopic surgery with lysis and lavage covering 10 years. On the bases of assessment of symptoms reported by the patients as well as objective signs noted on clinical examination confirmed resolution of pain on movement and increased maximal interincisial opening.. In a later study also lysis and lavage improved translation of the joint, decreased or eliminated pain. The chief presenting complaint for most patients (86,2%) was pain preoperatively. A significant maintained decrease in VAS score was achieved after 6 months and also after 5 years follow-up. A significant and maintained improvement in MIO was also observed over the same period of time (Leibur et al., 2010).The results are comparable to those reported in the other papers (Sorel and Piecuch, 2000; Smolka and Iizuka, 2005). It is important to take into account that the sympathetic and sensory nerve fibres within the temporomandibular joint are located in the anterior recess and the retrodiscal tissue of the upper compartment. Anterior disc release may reduce the number of these nerve fibres in arthroscopic procedures, thus influencing pain dynamics. The advantages of arthroscopy compared with open joint surgery using the Jaw Pain and Function Questionnaire are that arthroscopic surgery is less invasive and associated with lower morbidity (Undt et al., 2006). No statistical differences were also observed between arthroscopic lysis and lavage and operative arthroscopy in relation to postoperative pain or MIO at any stage of the follow-up period (Gonzalez – Garcia et al., 2008). The limitation in condylar movement probably originates from changes in the upper compartement that restricts the sliding motion of the disc. Arthroscopy improved the condylar movement. Arthroscopic lysis and lavage has been found effective in 84% of patients in case of osteoarthritis of TMJ (Dimitroulis, 2005). Multiple adhesions also develop skeletal changes, with a shortened ramus. If the condition develops rapidly enough, open

which may explain the failure to respond to conservative treatment.

bite and rethrognathia may occur ( Emshoff et al., 2003; Emshoff, 2005; Hamada et al., 2005). During arthroscopic surgery nodules of TMJ synovial chondromatosis are able to pass through the cannula by lavage with saline solution (Shibuy*a* et al., 2002). Based on the present findings, it follows that a displaced disc, by itself, is of only limited significance. This is not surprising because the majority of individuals with derangement of the TMJ are asymptomatic (Holmlund et al., 2001; Hamada et al., 2005). The intriguing question that remains is why lavage and lysis of adhesions or high-pressure irrigation of the upper joint space should be therapeutic. The answer is, that during this procedure several inflammatory mediators available in the synovial fluid as prostaglandins (K.I. Murakam*i* et al., 1998), cytokines (Kardel et al., 2003; Voog et al., 2003b), serotonin as pain mediator (Voog et al., 2000) etc. are washed out. In episodes of closed lock , the limitation in condylar movement probably originates from changes in the upper compartment that restrict the sliding motion of the disc. This course of events may explain the efficacy of lysis and lavage of only this joint space, as this manipulation allows translation of the disc along the eminence, allowing the condyle to complete its natural path. The data in the literature have stated that the most frequent disc displacements were anterior and anteromedial *(* Sorel & Piecuch, 2000). In episodes of closed lock , the limitation in condylar movement probably originates from changes in the upper compartment that restrict the sliding motion of the disc. The data in the literature have stated that the most frequent disc displacements were anterior and anteromedial. Using MRI pre- and postoperatively revealed that disc position remained anteriorly without reduction, disc mobility increased and deformity of the discs progressed after arthroscopic surgery (Ohnuki et al. 2003). Improvement in joint symptoms and function is not attributed so much as to the restoration of disc position as to possible release of the lateral capsular fibrosis during arthroscopy (Moses & Lo,1992; Sorel & Piecuch, 2000).

### **8. Arthroscopy vs. arthrotomy**

There is still a group of patients whom an arthrotomy and disc surgery are necessary e.g. to treat painful clicking in patients with anteriorly displaced, nonreducing discs and limited mouth opening, irreparable disc perforation or if it is misshaped , shortened, rigid (Laskin, 2006). Large medial osteophyts on the condyle are very difficult to shave arthroscopically, and in these situations they are better to handle *via* arthrotomy. Large central cartilaginous perforations may need an arthrotomy and possibly discectomy, although there are data about healing of disc perforations as the bilaminar zone undergoes metaplastic changes forming pseudodisc (Moses & Lo, 1992). The importance of disc position and shape is emphasized by many authors (Ohnuki et al., 2003; Politi et al., 2007). As a result, open joint procedures are developed to reposition the displaced disc (Holmlund et al., 2001; González - Garcia et al., 2008). Direct comparison of the clinical results are achieved in patients following arthroscopic surgery with a group of patients who underwent open surgery. The postoperative follow-up period ranged 5 to 6 years and 9 months. These results following open and arthroscopic surgery measured with the Jaw Pain and Function Questionnaire a self rating scale, originally published by Clark et al., 1989; and differentiated by Wilkes´(1989) stages. No significant difference was noted when comparing the groups 5 years postoperatively (Undt et al., 2006).

#### **9. Summary**

Clinical success of arthroscopy is based on several factors. Lysis and lavage remove intraarticular inflammatory and pain mediators. The release of fibrillations and adhearences

Temporomandibular Joint Arthroscopy 23

González-Garcia, R.; Rodriguez-Campo, FJ.; Monje, F.; Sastre-Perez, J.& Gil-Diez

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as well as improvement in discal mobility allows to distrbute the functional stresses on the articular tissues and adverse loading on the joints is decreased. The long-term outcome of TMJ arthroscopic surgery with lysis and lavage is considered to be acceptable and effective. Fibrillations and fibrous adhesions are the most usual pathological signs of arthroscopic findings in patients with internal derangement of the TMJ. Arthroscopic releasing of these restrictive bands improves the joint mobility and contributes to reducing pain level. The results of arthroscopy offer favourable long-term stable results with regard to increasing MIO and reducing pain and dysfunction. The improvement in joint mobility and disc mobility will lead to adaptive changes in the hard tissues .This may implay that the arthroscopic procedure with mechanics may stop the process of further TMJ degeneration. The advantages of arthroscopy compared with open joint surgery are that arthroscopic surgery is less invasive, procedure needs less time and associated with lower morbidity.

#### **10. References**


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**Part 2** 

**Arthroscopy of the Upper Extremity** 

