Arthroscopic surgery for treatment of temporomandibular joint hypomobility after mandibular sagittal osteotomy Bruce Sanders, DDS,a Ronald Kaminishi, DDS,b Ralph Buoncristiani, DDS,a and Chris Davis, DDS, IVD,~ Santa Monica, and Bellflower, Calif.

Arthroscopic surgery is an effective method for treating painful hypomobility of the temporomandibular joint. Decreased range of motion after sagittal ramus osteotomies of the mandible has been reported. Causes may include intra-articular factors. These cases may be effectively treated with arthroscopic lysis and lavage after failure of nonsurgical modalities. A series of 15 patients is presented. (ORALSURG ORALMEDORALPATHOL 1990;69:539-41)

D ecreased range of mandibular motion after sag- ittal ramus osteotomy for mandibular advancement has been reported by several authors.lm3 Investigations have been carried out to study the effects of postop- erative intermaxillary fixation versus the effects of rigid ramus fixation. Ellis4 carried out an experimen- tal investigation in Macaca mulatta and concluded that mandibular sagittal advancement osteotomy combined with intermaxillary fixation is more detri- mental to range of motion than surgical treatment alone. Ellis points out that factors that can produce decreases in range of motion secondary to immobili- zation and surgical treatment can be classified as in- tra-articular, muscular, and connective tissue.

If the hypomobility is caused by extra-articular re- strictions, physiotherapy2 may be extremely helpful in reestablishing satisfactory mandibular movement and function. However, if there is a resultant internal de- rangement with persistent closed lock or painful lim- itation of movement due to degenerative joint disease, surgical intervention may have to be employed if con- servative measures are exhausted.

Sanders5 reported that arthroscopic surgery to cor- rect persistent closed locking of the temporomandib- ular joint appears to be an alternative to arthrotomy. Sanders and Buoncristiani6 have reported a large se- ries of patients with mandibular hypomobility sec- ondary to closed lock or arthrosis with adhesive cap-

aPrivate practice. Santa Monica, Calif bPrivate practice, Bellflower, Calif. 7/12/18074

sulitis who were effectively treated with arthroscopic surgery.

The purpose of this article is to present the com- bined experience of the authors with the management of mandibular hypomobility status post-sagittal os- teotomy.

CLINICAL FINDINGS

Fifteen patients, all female, were treated with sag- ittal osteotomies to correct a developmental mandib- ular retrognathism. None of the patients had any se- vere form of temporomandibular joint disease preop- eratively although most had some positive findings such as clicking.

The typical complaint after orthognathic surgery and orthodontics was preauricular pain and mandib- ular hypomobility. The range of duration of these symptoms before arthroscopy was from 5 months to 2 years, 7 months. The average duration of symptoms was 1 year, 3 months.

Thirteen of the patients had bilateral joint prob- lems. Two of the patients had unilateral problems of pain and hypomobility. Of the 28 involved joints, 8 joints had the clinical diagnosis of closed lock, 13 joints had the diagnosis of closed lock with some de- generative changes, and 6 joints had the diagnosis of significant degenerative joint disease.

All of the patients had radiographic imaging in the form of arthrograms or magnetic resonance imaging. They all had tomography as well. Twenty-four of the twenty-eight joints had a nonreducing anteriorly dis- placed disk. Two showed a reducing anteriorly dis- placed disk. Twenty-six of the twenty-eight joints ex-

539

540 Sanders et al. ORAL SURG ORAL MED ORAL PATHOL May 1990

Table I.

Duration of symptoms Preop Postop TMJ Clinical Radiographic Signs and Arthroscopic opening opening

, surgery Sex side Years Months diagnosis findings symptoms jindings (mm) (mm) -

1

2

3

4 5

6 I

8

9

10

11

12

13

14

15

31

46

32

15 17

47 37

40

41

22

30

36

17

20

41

R 0 9 DJD RAD,DJD L 0 9 DJD NRAD,DJD R 1 0 CL DJD,NRAD L 1 0 CL DJD,NRAD R 2 9 CL,DJD MC,DJD,NRAD L 2 9 CL,DJD MC,DJD,NRAD R 0 6 DJD DJD,NRAD R 1 9 DJD DJD,NRAD L 1 9 DJD DJD,NRAD L 1 11 DJD MC,DJD R 0 7 CL MC,RAD L 0 7 CL DJD R 0 5 CL,DJD DJD,NRAD L 0 5 CL,DJD DJD,NRAD R 0 10 CL,DJD DJD,NRAD L 0 10 CL,DJD DJD,NRAD R 1 6 CL,DJD NRAD,DJD L 1 6 CL,DJD NRAD,DJD R 1 7 CL,DJD NRAD,CL,P,MC L 1 7 CL,DJD NRAD,CL,MC,DJD R 1 3 CL,DJD NRAD,DJD L 1 3 CL,DJD NRAD,DJD R 1 0 CL,DJD NRAD,DJD L 1 0 CL,DJD NRAD,DJD R 2 0 CL DJD,NRAD L 2 0 CL DJD,NRAD R 0 10 CL NRAD L 0 10 CL NRAD

Clinical diagnosis: CL = closed lock. DJD = degenerative joint disease.

Signs and symptoms: P = pain. H = hypomobility.

P,H

P,H

P,H

P,H P,H

P,H P,H

P,H

P,H

P,H

P,H

P,H

PJ-J

P,H

P,H

SAP W PA A

AS A3 ps P,A

P AS AS A3 A

AS AS AS

MC,A,EF MC,A,EF,S DI,MC,A,S DI,MC,A,S

MC,A A,MC,P

MC,A,DI,S MC,A,DI,S MC,A,DI,S MC,A,DI,S MC,A,DI,S MC,A,DI,S

25

29

27

39 39

23 16

30

26

31

26

20

22

28

23

35

35

35

41 42

35 34

40

36

40

38

35

38

42

37

Radiographic findings: Arthroscopic findings: NRAD = non-reducing anteriorly displaced disk. MC = morphologic changes. RAD = reducing anteriorly displaced disk. A = adhesions. DJD = degenerative joint disease. EF = eburnation of fossa MC = morphologic changes H = hyperemia.

(remodeling or positional). S = Synovitis. P = perforation of disk. DI = displaced disk.

hibited some type of morphologic change of the soft and/or osseous tissues in addition to disk displace- ment. Twenty-four of these twenty-six morphologic changes were read out as degenerative changes.

Preoperative interincisal opening ranged from 16 to 39 mm. The average opening was 27 mm. All joints had significant preauricular pain.

Arthroscopic surgery was done as an outpatient procedure with the patient under general anesthesia. The surgery involved lysis of adhesions, lavage and drainage, and manipulation of the mandible. No sig- nificant postoperative complications were encoun- tered and recovery was uneventful. A physical ther- apy regimen was instituted for all patients.

Arthroscopic findings of the 28 joints included 6 joints with perforations or destroyed disks, 26 joints with adhesions, and 20 joints with synovitis.

Postarthroscopy opening ranged from 34 to 42 mm

P = perforation.

with an average of 38 mm. Improved range of open- ing varied from 2 mm improvement (these had 39 mm preoperatively) to 18 mm improvement with an aver- age of 11 mm improvement. Pain levels were im- proved significantly in all patients. Postoperative fol- low-up varied from 6 months to 4 years.

SUMMARY

Temporomandibular joint pain and hypomobility associated with closed lock or degenerative joint dis- ease is not an uncommon finding after mandibular osteotomy via sagittal split. These findings have been seen when intermaxillary fixation or rigid fixation was used.

If nonsurgical therapy is unsuccessful in alleviating this condition, arthroscopic surgery with lysis and la- vage followed by active physical therapy seems to be an effective treatment modality.

Volume 69 Number 5

REFERENCES

1. Storum KA, Bell WH. Hypomobility after maxillary and mandibular osteotomies. ORAL SURG ORAL MED ORAL PATHOL 1984;57:7-12.

2. Storum KA, Bell WH. The effect of physical rehabilitation on mandibular function after ramus osteotomies. J Oral Maxillo- fat Surg 1986:44:94-9.

3. Aragon SB, Van Sickles JE, Dolwick MF, et al. The effects of orthognathic surgery on mandibular range of motion. J Oral Maxillofac Surg 1985;43:938-43.

4. Ellis E. Mobility of the mandible following advancement and maxillomandibular or rigid internal fixation: an experimental investigation in Mucaca mulatta. .I Oral Maxillofac Surg 1988;46:118-23.

Arthroscopic surgery for TMJ hypomobility 541

5. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. ORAL SURG ORAL MED ORAL PATHOL 1986;62:361-72.

6. Sanders B, Buoncristiani R. Diagnostic and surgical arthros- copy of the temporomandibular joint: clinical experience with 137 procedures over a 2-year period. J Craniomandibular Dis- orders-Facial and Oral Pain 1987; 1:202- 13.

Reprint requests to: Dr. Bruce Sanders Suite 213 1304 15th St. Santa Monica, CA 90404