Miles Poor

Miles Poor (Abstract, 16 April)

Why the TMJ complicates the art and the science of dentistry

The TMJ is the only Joint in the body associated with teeth.  It has the ability to confuse the practitioner with a multitude of signs and symptoms.  This lecture will serve as an introduction to the concept of multidisciplinary co-operation in the diagnosis and management of TMJ problems.

Lecture outline:

1. The technical terminology- Ginglimodiarthrodial Joint. If that doesn’t stir your emotions, nothing will
2. Only Joint in Body associated with Teeth
3. How does that relationship impact us?
4. Are the teeth directly impacting how the joint functions?  Yes and No!
5. At rest the teeth are not in contact.  They contact approximately 17 times a minute.
6. Can this impact the physiology of the joint?
7. Absolutely!
8. if CO and CR are the same.
9. if there are Distalizing Forces.
10. and if there are Balancing Interferences.
11. Pathophysiology involves the Muscles and the intra articular components.  Nerves, blood vessels, synovial tissue, cartilage and bone
12. MPD Syndrome vs Capsulitis vs Meniscal Mobility Syndrome
13. Treatment?
14. Multidisciplinary
15. No one sub specialty can completely manage these complex patients
16. Successful outcomes are not always Treatment Driven
17. Patient Expectations vs Reality
18. Remember! No One Succumbs to TMJ Disease
19. Set Realistic Goals and Interventions
20. Never be afraid to not treat.  It is not a Sign of weakness but of Experience
21. Remember the Hippocratic Oath “Do Not Harm the Patient”
22. Remember the Difference Between This Joint and all others in the body: Fibrocartilage Vs Hyaline Cartilage
23. The TMJ can heal itself.
24. Our Goals should  always be to help it along and not interfere with the process.

Lecture on Micro disc surgery of TMJ:

1. Understanding the changes that occur to the meniscus and how they  influence surgical intervention: microdisc vs arthroscopy vs arthrocentesis
2. Radiographic interpretation. MRI vs CBCT
3. Phases of meniscal deformation, grade 1, 2, 3 deformities
4. The micro anatomy that controls disc positioning . Lateral and medial collateral ligaments.  Fan shaped posterior lateral ligament.  Why they are different and their importance in joint architecture
5. We are working in a space of 1.7 cc superior and .7-8 cc inferior.  This is tight quarters.
6. Incisions need to be parallel capsular fibers not perpendicular.  No disruption of capsular architecture.
7. Capsule fans out with upper space fibers parallel to the fossa and lower space capsule fibers obliquely oriented.   These dictate the surgical incisions in micro disc techniques
8. Causes of disc displacement. Trauma, micro trauma, growth, autoimmune and tumors.
9. As with orthopedic injuries, traumatic displacement of a meniscus must be repositioned within a short time span
10. Only grade 1 and early grade 2 discs lend themselves to micro disc ligament repair.
11. It is as important to secure the lateral attachments as it is to position the disc ap.
12. The micro disc technique relies on positioning of the ligaments so that Sharpie fibers can reattach to the bone.
13. The TransTragal incision approach
14. Developed by Sheffield and Poor in 1985. Published by Van Sickles as the Endaural incision in the late 1980’s
15. Designed to minimize tissue trauma and visible scarring.
16. Approach keeps auriculotemporal nerve, superficial temporal vein, superficial temporal artery and facial nerve in front of the joint.  Affords minimal blood loss and post op swelling.  Allows for visualization of capsular fibers.   Parotid sparing minimizing chance of Frey’s Syndrome.
17. This approach affords direct access to the upper joint space if arthroscopy is included in micro disc surgery( type 2 disc deformities)
18. Lateral flexure reconstruction is as important as the correct positioning of the disc and approach allows for this with no disruption of the capsular fibers
19. Lateral entrapment syndrome , best visualized with CBCT.
20. If disc deformity is late grade 2-3 there is no option to reposition meniscus.  It won’t fit.   Load is in lateral 1/3 of joint and compression of synovial tissues can result in ICR.   Eminoplasty or Load Transfer procedures work best along with retrodiscal cauterization.
21. Adaptive nature of retrodiscal tissues
22. Long term studies done in Scandinavia show that disc displacement is typically self healing.  MRI assessment of chronically displaced discs show areas of retrodiscal fibrosis that have signal intensity similar to posterior band.
23. Options for Grade 3 deformed discs include : no intervention, arthrocentesis with or without PRP, arthroscopic retrodiscal cauterization with lysis of synovial bands, partial or complete menisectomies if perforations are found.
24. Regardless of what is done to a joint, the post op management is as critical as the surgery.  Diet, physical therapy, splint therapy all are  modalities we use to allow for correct healing.Opening to greater than 40 mm is essential.
25. Non chew diet for 6 weeks.  At six weeks the ligament has 30 percent strength.  Chewing on ipsilateral side operated to begin.  Soft and small portions.
26. At three months ligament has 80 percent strength and chewing permitted on both posterior sides.
27. At 6 months healing complete and biting with front teeth permitted.
28. Intra articular MS, blocking with marcaine and six week course of NSAIDs.
29. Surgery takes an hour, the cure takes patient management for six months.
30. In early grade 2 disc repositioning an anterior repositioning device must be used.  This often results in a posterior openbite requiring Orthognathic surgery to correct occlusion.
31. Complications
32. Intra articular fibrosis.  Synovial banding resulting in lom and pain.
33. Numbness to temple( auriclotemporal nerve neuropraxia.  Resolves spontaneously
34. Malocclusion.
35. Failure to recapture disc.
36. Re-operation rate less than 1 percent
37. Post op complications are typically secondary to poor post op physical therapy and diet management.
38. Surgery is easy/ recovery is the hard part….
39. Micro disc surgery works superbly in condylar hyperplasia cases where the meniscus is in a normal pre-op position and has normal morphology.
40. There are no residual materials left in the joint that could cause issues later on.
41. No scar!
42. In the age of endoscopic and Natural Orifice surgery ( NOTES), it is still acceptable to make skin incisions.