SUPPLEMENT

TEMPOROMANDIBULAR ARTHROSCOPY AND JOINT SURGERY

Supported by an educational grant from

WALTER LORENZ SURGICAL INSTRUMENTS, INC. Jacksonville, Fla.

Silicone rubber fossa implant removal via partial arthrotomy followed by arthroscopic examination of the internal surface of the fibrous capsule Bruce Sanders, DDS,n Ralph D. Buoncristiani, DDSb and Loche Johnson, DDS.c Los Angeles, Cali$

SECTION OF ORAL AND MAXILLOFACIAL SURGERY, UCLA SCHOOL OF DENTISTRY

Thirteen temporomandibular joints were examined arthroscopically for evaluation for fibrous encapsulation of silicone elastomer disk replacement implants. Partial arthrotomies were performed with removal of silicone rubber implants, followed by arthroscopic examination of the internal surfaces of the fibrous capsule. Examinations were performed to determine the functional capacity for the residual fibrous capsule as a pseudodisk and to verify the continuity of the fibrous barrier between the condyle and the fossa. (ORAL SURC ORAL MED ORAL PATHOL 1990;70:369-71)

S ince the introduction of the Watanabe No. 24 ar- throscope in 1975 by Ohnishi,’ arthroscopy has expanded its diagnostic and therapeutic treatment spectrum. The first clinical applications of arthrosco- py, as discussed by Ohnishi,2 were limited to diagno- sis of various pathosis. With further anatomic and clinical investigations by Murakami and cowork- ers,3-5 arthroscopy assumed a greater role in treat- ment of temporomandibular joint (TMJ) disorders.

The therapeutic value of TMJ arthroscopy has gained much popularity and success in recent years.

aAdjunct Professor. bLecturer. CResident. 7/Q /I3337

Good clinical results in the treatment of acute and chronic closed lock, and degenerative joint disease by SandersP, ’ give a promising outlook for TMJ ar- throscopy.

SURGERY

Thirteen TMJs in nine patients were treated by re- moval of silicone elastomer implant and arthroscopic evaluation of the residual fibrous barrier. Abbreviated preauricular incisions through previous surgical sites were used. The entire TMJ was not opened. Only a small incision overlying the lateral surface of the im- plant was employed. A periosteal dissection was per- formed to visualize the fixation wire for the implants. With the use of fine retractors, the outline of the fi- brous capsule was delineated. A lateral incision oppo- site the implant aided in removal and release of the sili-

369

370 Sanders, Buoncristiani, and Johnson ORAL SURG ORAL MED ORAL PATHOL September 1990

Fig. 1. Post-implant removal arthroscopic view between fossa and fibrous barrier. A, Note relatively smooth artic- ular surface of the fibrous barrier similar to that of a disk. B, Medial synovial lining.

cone rubber implant. With the use of a 1.9 mm Wolf arthroscope (Richard Wolf Medical Instruments, Rosemont, Ill.), the interior aspect of the fibrous cap- sule was evaluated for continuity (Figs. 1 and 2).

PATIENTS

All patients in the study had previous disk removal with placement of silicone implant. Patient symptoms before retrieval were localized pain in all affected joints with headaches in six patients. All patients were female with ages ranging from 24 to 52 years. Dura- tion of symptoms varied from 3 years to 8% years. Clinical and radiographic diagnoses of degenerative joint disease were present in all cases.

Silicone removal with arthroscopic evaluation had favorable postoperative results. Six of the patients had excellent results with significant improvement in pain symptoms. The remaining three patients had good results with improvement in symptoms and function. The postoperative results date from 2 years and 5 months to 1 month. Smooth articular surfaces were seen in more than 90% of fibrous barriers observed.

DISCUSSION

Open joint procedures have been an accepted treatment for many TMJ disorders, including closed lock.8 Alloplastic materials were introduced as disk replacements during meniscectomy.g Because of the success of silicone elastomer phalangeal reconstruc- tion by Swanson,l” there has been an increased use of silicone in the TMJ as a disk replacement. Silicone elastomer is well tolerated by the body and becomes encapsulated by connective tissue in a reasonably

Fig. 2. Another post-implant removal arthroscopic view of intact fibrous barrier. Articular surface has several irregularities; however, pseudodisk appeared to be moving well with condylar movement and demonstrated an ade- quate soft tissue barrier between condyle and fossa.

short period of time. * ’ The connective tissue capsule is thick in nature, containing few blood vessels and abundant collagen fibers. I2 Because of the nature of the capsule, it works as a reasonably smooth articular surface. Recently, reports of untoward side effects from this implant material, if left in permanently, have been increasingly published. The most common of these are silicone rubber implant displacement,13 implant fragmentation, I4 foreign body response with s ynovitis, l 5 and recurrent joint pain.16

Removal of these implants with partial arthrotomy followed by arthroscopic confirmation of an intact pseudodisk fibrous barrier is an acceptable and rela- tively conservative technique to eliminate painful capsulitis.

REFERENCES 1. Ohnishi M. Arthroscopy of the temporomandibular joint. J

Stomatol Sot Jpn 1975;42:207-13. 2. Ohnishi M. Clinical application of arthroscopy in the tem-

poromandibular joint diseases. Bull Tokyo Med Dent Univ 1980;27:141-50.

3. Murakami K, Ito K. Arthroscopy of the temporomandibular joint third report; clinical experiences. Arthroscopy 1984;9:49- 59 (in Japanese, abstract in English).

4. Murakami K, Mats&i M, Iizuka T, Ono T. Diagnostic arthro- scopy of the TMJ: differential diagnosis in patients with limited jaw opening. J Craniomandibular Prac 1986;4:2,118-26.

5. Murakami K, Takatoki 0. Temporomandibular arthroscopy by inferolateral approach. Int J Oral Maxillofac Surg 1986; 15:410-2.

6. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. ORAL SURG ORAL MED ORAL PATHOL 1986;62:36 l-72.

7. Sanders B, Buoncristiani R. Diagnostic and surgical arthros-

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copy of the temporomandibular joint: clinical experience with 137 procedures over a 2-year period. J Craniomand Disorders: Facial and Oral Pain 1986;1:202-13.

8. Heffez L, Mahmood M, Rosenberg H, Langer B. CT evalua- tion of TMJ disc replacement with a Proplast-Teflon laminate. J Oral Maxillofac Surg 1982;45:657-65.

9. Marciani E, Popovich L, Gurnsey L. Alloplastic reconstruction of the temporomandibular joint. Dent Clin North Am 1986; 30:307-25.

10. Swanson AB. Finger joint replacement by silicone rubber im- plants, and its concept of implant fixation by encapsulation. Ann Rheum Dis 1969;28:47-55.

11. Bessette R, Katzberg R, Natiella J, Rose M. Diagnosis and reconstruction of the human temporomandibular joint after trauma or internal derangement. Plast Reconstr Surg 1985; 75192-203.

12. Laitung J, McClure J. The fibrous capsule around static and dynamic implants: their biochemical, histological, and ultra- structural characteristics. 1987;19:209-14.

13. Marciani E, Popovich L, Gurnsey L. Alloplastic reconstruction of the temporomandibular joint. Dent Clin North Am 1986; 30:307-25.

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Westesson P, Erikson L, Lindstrom C. Destructive lesions of the mandibular condyle following diskectomy with temporary silicone implant. ORAL SURG ORAL MED ORAL PATHOL 1987; 63:143-50. Dolwick M, Aufdemarte T. Silicone-induced foreign body re- action and lymphadenopathy after temporomandibular joint arthroplasty. ORAL SURG ORAL MED ORAL PATHOL 1985; 59~449-52. Eriksson L, Westesson PL. Deterioration of temporary silicone implant in the temporomandibular joint: a clinical and arthro- scopic follow-up study. ORAL SURG ORAL MED ORAL PATHOL 1986;62:2-6.

Reprint requests to: Dr. Bruce Sanders Section of Oral and Maxillofacial Surgery UCLA School of Dentistry Center for the Health Sciences Los Angeles, CA 90024