Journal of Maxillofacial and Oral Surgery

Temporomandibular Joint Surgery for internal disorders: Decompression of the

superior joint space.
--Manuscript Draft--

Manuscript Number: MAOS-D-21-00070R1

Full Title: Temporomandibular Joint Surgery for internal disorders: Decompression of the
superior joint space.

Article Type: Original research

Corresponding Author: David Abisay Valdés Martínez, Maxillofacial Surgeon, private practice
Hospital de Especialidades Centro Medico Nacional Siglo XXI
Ciudad de México, Ciudad de México MEXICO

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Hospital de Especialidades Centro Medico Nacional Siglo XXI

Corresponding Author's Secondary

Institution:

First Author: Jose Manuel Garcia y Sanchez, Maxillofacial Surgeon

First Author Secondary Information:

Order of Authors: Jose Manuel Garcia y Sanchez, Maxillofacial Surgeon

David Abisay Valdés Martínez, Maxillofacial Surgeon, private practice

Martin Elizalde Monroy, Maxillofacial Surgeon

Juan Jose Estrada Orozco, Maxillofacial Surgery 4th year resident Maxillofac

Jorge Alfredo Reynaga Martinez, Maxillofacial surgeon

Jairo Pedraza Jimenez, Maxillofacial Surgery 3th year resident Maxillofac

Sindy Katerine Vera Castellanos, Master in Orthodontics and Maxillofacial Orthopedi

Grecia Daniela Arce Fernandez, Maxillofacial Surgeon

Order of Authors Secondary Information:

Funding Information:

Abstract: Summary.

Background. Internal disordees of the temporo-mandibular Joint (IDTMJ) are an

important area, represented by 20% of the maxillofacial surgeon's practice today. The
patients with ITATM who would merit a surgical procedure, would represent 1 to 3% of
the population worldwide, represented in its great majority by women. For their relief,
they have been used from minimally invasive palliative procedures, to open surgery to
obtain a definitive correction.

Purpose . This work will demonstrate the cornerstone of the definitive treatment
through open surgery. It will do this by showing how to achieve internal decompression
of the two most important affected structures of the temporo mandibular joint (TMJ),
the articular meniscus (AM) and the mandibular condyle (MC), through total
decompression of the entire surface of the AM from the upper compartment and the
articular tubercle eminectomy (ATE). It is a mechanical effect of movement and
compression. The approach proposed is the Bat Wing, a modified retro auricular
approach without sectioning the external auditory canal (EAC), since it is done by
providing 5 cm of space from the starting point of the EAC to the front part of the
articular tubercle (AT), without damaging the seventh frontal cranial branch nerve or
tearing the AM or the joint capsule.

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Methods. ITDMJ interventions were performed on 84 patients, 81 women and 3 men.
Results. The asymptomatic percentage with zero pain among the patients operated
on was 94% of the total, with a success rate of 100%, on 79 patients. Light post-
operative clicking was experienced by 26 patients, or 30%. Recurrence occurred in 6%
of the sample, or 5 patients. Compulsory anxiety disorders and bipolarity were
presented in all 5, of whom 3 had attempted suicide, and 3 also were associated with
fibromyalgia. A total of 165 joints were operated on over 7 years.
We offer an apology since it was our mistake. The article continues with the same
authors including Dr. Grecia Daniela Arce Fernandez. The fact of having divided the
manuscript into two parts, made that when making its corresponding correction we
omitted one of the authors and when wanting to add one more author who is Dr. Sindy
Katerine Vera Castellanos because she made contributions in question of edit,
translate changes and add some content that will contribute to this new version of our
article. We appreciate your understanding. Good morning.
Title Page

Temporomandibular Joint Surgery for internal disorders: Decompression of the su-

perior joint space.

*García y Sanchez Jose Manuel. Email; maxilofacialcirugiasuperlativa@gmail.com

**Valdes Martínez David Abisay. Email; cmfvaldes@hotmail.com
***Elizalde Monroy Martin. Email; elizaldecmf@live.com.mx
****Estrada Orozco Juan José. Email; juanjosestrada16@gmail.com
*****Reynaga Martínez Jorge Alfredo. Email; reynaga08@hotmail.com
******Jairo Pedraza Jimenez. Email; jairopedrazajimenez@icloud.com
*******Vera Castellanos S. Katerine. Email; katevera.ortodoncia@outlook.com
********Grecia Daniela Arce Fernandez; fairydail@hotmail.com

Author identifying information:

*Maxillofacial surgeon, Maxillofacial Surgery Department, Medical Specialities Hospital,
Centro Medico Nacional Century XXI. Instituto Mexicano del Seguro Social (IMSS). Mexico
city, México.
** Maxillofacial surgeon, private practice. Mexico city, México.
***Maxillofacial surgeon, Maxillofacial Surgery Department, Medical Specialities Hospital,
Centro Médico nacional Century XXI. Instituto Mexicano del Seguro Social (IMSS). Mexico
city, México.
****Maxillofacial Surgery 4th year resident Maxillofacial Surgery Department, Medical Spe-
cialities Hospital, Centro Médico Nacional Century XXI, Instituto Mexicano del Seguro So-
cial. Mexico city, México.
*****Maxillofacial surgeon, Regional Hospital of Zone #1 IMSS, Villa de Alvarez, Colima,
Mexico.
******Maxillofacial Surgery 4th year resident Maxillofacial Surgery Department, Medical
Specialities Hospital, Centro Médico Nacional Century XXI, Instituto Mexicano del Seguro
Social. Mexico city, México.
*******Master in Orthodontics and Maxillofacial Orthopedics, Private Practice. Mexico city,
Mexico.
********Maxillofacial surgeon, Regional Hospital #2, Instituto Mexicano del Seguro Social.
Ciudad de Mexico, Mexico.

Compliance with ethical standards

No funding was needed
There are no conflicts of interest within the authors.
Summary.

Background. Internal disordees of the temporo-mandibular Joint (IDTMJ) are an important

area, represented by 20% of the maxillofacial surgeon's practice today. The patients with
ITATM who would merit a surgical procedure, would represent 1 to 3% of the population
worldwide, represented in its great majority by women. For their relief, they have been used
from minimally invasive palliative procedures, to open surgery to obtain a definitive correc-
tion.

Purpose. This work will demonstrate the cornerstone of the definitive treatment through open
surgery. It will do this by showing how to achieve internal decompression of the two most
important affected structures of the temporo mandibular joint (TMJ), the articular meniscus
(AM) and the mandibular condyle (MC), through total decompression of the entire surface
of the AM from the upper compartment and the articular tubercle eminectomy (ATE). It is a
mechanical effect of movement and compression. The approach proposed is the Bat Wing,
a modified retro auricular approach without sectioning the external auditory canal (EAC),
since it is done by providing 5 cm of space from the starting point of the EAC to the front
part of the articular tubercle (AT), without damaging the seventh frontal cranial branch nerve
or tearing the AM or the joint capsule.

Methods. ITDMJ interventions were performed on 84 patients, 81 women and 3 men.

Results. The asymptomatic percentage with zero pain among the patients operated on was
94% of the total, with a success rate of 100%, on 79 patients. Light post-operative clicking
was experienced by 26 patients, or 30%. Recurrence occurred in 6% of the sample, or 5
patients. Compulsory anxiety disorders and bipolarity were presented in all 5, of whom 3
had attempted suicide, and 3 also were associated with fibromyalgia. A total of 165 joints
were operated on over 7 years.
Blinded Manuscript Click here to view linked References

1
2
3
4 Background.
5
6
Internal disorders of the TMJ are defined as the antero-medial displacement of the articular
7
8 disc when the teeth are in maximum intercuspidation, causing reciprocal clicks and limita-
9 tion. Disc displacements are pathogenic and become degenerative. In 1979, McCarty, W. &
10 Farrar, W. described the technique of reconstructive arthroplasty and repositioning of the
11 disc for internal TMJ disorders by means of a hockey stick shaped preauricular approach
12 derived from 327 surgical operations over 6 years, reporting a 94% success rate in their
13 evaluation. [1].
14
15 Wilkes, C. 1991 performed a surgical follow-up on 176 patients (211 joints) with IDTMJ using
16
three different surgical procedures: meniscectomy, reconstructive arthroplasty, and arthro-
17
18 plasty with a temporary silastic implant. He obtained an overall success rate of 93.8%, while
19 demonstrating that reconstructive arthroplasty provides better results than meniscectomy or
20 arthroplasty with a silastic implant [2].
21
22 In 1991, Dolwick commented that the surgical treatment of the internal disorders of the TMJ
23 have proved to be effective for reducing pain and increasing the range of movement in 80%
24 of patients regardless of the surgical technique used [3].
25
26
27 In 1993, García y Sánchez presented a modified retro-auricular approach without sectioning
28 the EAC to address the TMJ [4].
29
30 In 2001, Mehra, P & Wolford, L. evaluated the treatment of 105 patients (188 discs) using a
31 mini mitek anchor in the posterior part of the condyle for repositioning the articular disc, with
32 significant reduction of TMJ pain, facial pain, headache, joint noises, and incapacity, with
33 improvement of the masticating function [5].
34
35
In 2007, Dolwick commented that the most important finding is that the pain and dysfunction
36
37 arise within the TMJ. The more localized the joint pain and dysfunction is, the better will be
38 the prognosis for surgical intervention. The decision to operate and the selection of the pro-
39 cedure are based on clinical experience [6].
40
41 In 2010, Abramowicz, S. and Dolwick, F. commented that the follow-up of 18 patients over
42 20 years (36 joints) treated by repositioning the articular disc showed a significant reduction
43 in pain with a success rate of 94%. [7]
44
45
46
Management of open ITDMJ surgery has been established as the treatment of patients who
47 do not respond to conservative treatments. However, damage to the adjacent anatomical
48 structures could become an important concern while performing TMJ surgery [7-11].
49
50 In 2014, García y Sánchez described the “Bat-Wing” approach as an alternative that offers
51 major advantages, such as avoiding damage to the facial nerve and sectioning the auditory
52 canal, while providing a broad view of the surgical field [12).
53
54
Dongmein, He and Yang, Chi, in 2014, in open TMJ surgery, passed a suture from the back
55
56 of the disc and held it in the bilaminar zone, opening the auricular cartilage, making a knot,
57 and burying it in the skin [13].
58
59
60
61
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 1
2
3
4 Ruiz Valero, also in 2014, described the modified endaural approach for the TMJ, in 20
5 years of experience with 1,000 joint interventions, providing greater breadth than the classic
6
endaural approach [14].
7
8
9 In 2017, Candirli, C. et al. commented on their retrospective study of 31 patients with differ-
10 ent surgical treatments for IDTMJ. They describe more effectiveness in disc excision without
11 a graft, but especially with the replacement. It effectively reduces pain and restores the func-
12 tioning of the jaw without problems. Although the eminectomy appears to improve maximum
13 mouth opening, it has a high failure rate (50%), as shown by the persistence of post-opera-
14 tive pain [15].
15
16
17
18 Material and Methods.
19 Decompressive surgery and internal disorders of the TMJ using the Bat Wing approach were
20 performed on 84 patients between 2013 and 2020, all of them done by Dr. García y Sánchez.
21 A similar number were performed by the other maxillofacial surgeons, which make up the
22 group of specialists in the Maxillofacial Surgery service of the Hospital of Specialties in the
23 Centro Medico Nacional Siglo XXI of the Mexican Institute of Social Insurance. Size 702L
24 Lindemann burs and size 8 ball were also employed. An ultrasonic micro-tip cutter and com-
25
puterized tomography of the facial massif were also used on each patient.
26
27
28
29
30 Approaches to TMJ Surgery
31
32
33 The preauricular approach is excellent for accessing the TMJ directly and quickly with
34 good exposure. It is also particularly useful for the sub condylar region, and is used in sub
35
condylar fractures, ankylosis, tumors in the articular regions, and IDTMJ. To perform surgery
36
37 on the medial wall of the AT glenoid cavity in the medial part, the frontal branch may be
38 damaged, causing temporal paresis, since the exposed operative field is reduced to no more
39 than 2.5 cm. (Fig. 1).
40
41
42
43
44
45
46
47
48
49
50
51 (1)
52
Fig. 1. View of the preauricular approach, where the AT is identified by the blue arrow, the AM by the
53 green arrow and the MC by the yellow arrow.
54
55 The preauricular approach, modified by AI Kayat and Bramley, is an extension
56
of the preauricular to achieve greater exposure of the lower part of the temporal mus-
57
58 cle. (Fig. 2).
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8
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15
16 (2)
17 Fig. 2. Preauricular approach modified by Bramley and AI Kayat.
18
19 The retro-auricular approach. This access to the mastoids is also used to access
20 the TMJ, by cutting the EAC. It was made known by Bokenheimer in 1920. The use-
21
fulness for approaching the TMJ is reduced only in the bilaminar zone and the back
22
23 part of the retro-condylar (Fig. 3).
24
25
26
27
28
29
30
31
32
33
34
35
36 (3)
37
38 Fig. 3. Retro-auricular approach. Observe the sectioned EAC, the retro-condylar access entering the
bilaminar area with the insertion of the meniscus.
39
40
41
The modified retro-auricular approach was described by García y Sánchez in
42 1993, taking the idea of the retro-auricular approach for mastoids, with the modifica-
43 tion of surrounding the upper part of the EAC, to later lower the dissection and reach
44 to the AT in the frontal part, without damaging or cutting the EAC (Fig. 4).
45
46
47
48
49
50
51
52
53
54
55 (4)
56
57 Fig. 4. EAC, blue arrows. Glenoid cavity green arrows, plication disk yellow arrow.
58
59 The endaural approach and modified endaural approach. The first endaural ap-
60 proach was described in 1938 by Lempert J., an otorhinolaryngologist. Later, in 1954,
61
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2
3
4 Rongetti modified it for treating TMJ problems, performing a meniscectomy. The
5 classic endaural approach has a reduced field, due to the limitation that the flap can-
6
not be enlarged much for performing surgery of the AT comfortable depth, as can be
7
8 seen in (Fig. 5). The modified endaural was described by Dr. Ruiz Valero in 2014,
9 providing greater enlargement of the operative bed [14]. (Fig. 6).
10
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12
13
14
15
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17
18
19
20
21 (5) (6)
22
Fig. 5. Classic endaural approach. Fig. 6. Modified endaural approach. ZA, Zygomatic arch. AD, Artic-
23
ular disc.
24
25 The retro-auricular Bat Wing Approach. Described in 2014 by García y Sánchez, it
26 is a variation of the modified retro-auricular approach, smaller and broader in the field
27
28 of operation. It is the ideal approach for the dissection and release of the periosteum
29 from the cavity and the front and medial part of the AT to completely release the AM
30 in the upper compartment of the meniscus. It has an operative field of between 5.5
31 and 6 cm. It is the broadest operating field with respect to the techniques described
32 today. (Fig. 7).
33
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39
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42
43
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45
(7)
46
47 Fig. 7. Bat Wing Approach.
48
49 Surgical Anatomy of the Temporo-Mandibular Joint. A.- Relevant points for perform-
50 ing the “Bat Wing” approach.” B.- Dissection of the upper compartment and joint de-
51 compression.
52
53
54 A.- To perform open surgery of the TMJ using the Bat Wing approach (Fig. 8), the first wing
55 of the temporal region of the approach will be deployed until reaching the temporal fascia,
56 which will be the key point for avoiding damage to the seventh cranial nerve, in its frontal
57 branch. It will find different depths by planes as can be seen (Fig. 9).
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12
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18 (8) (9)
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20 Fig. 8. Design of the Bat Wing. Fig. 9. Schematic diagram showing the different depths of the seventh cranial
21 nerve and the temporal fascia.
22
23 Once the temporal fascia is located, the superficial musculoaponeurotic system is drawn in
24 toward the lower part of the anterior Bat Wing. These are the anatomical points to consider,
25 as may be seen in (Fig. 10).
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34
35
36
37
38
39
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41 (10)
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43 Fig. 10. Drawing with the unfolding of the flap corresponding to the front wing of the Bat Wing.
44
45 The other important anatomical point for performing the Bat Wing will be locating the EAC,
46 taking the dissection to the root of the temporal bone found 5 mm horizontally from the upper
47 part of the EAC. The blue arrow shows the upper part of the EAC for accessing the root of
48 the temporal bone, as shown in the following (Fig. 11). The next anatomical site is in the
49 temporal root. It will be crucial to open the dissection until you get to the front part of the AT.
50
51
With the different blue arrows, you can see the region that approaches the EAC. The green
52 arrows show the GC; the yellow arrows the AT region (Fig. 12).
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16 (11) (12)
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18 Fig. 11. Access to the EAC. Fig. 12. Complete deployment of the Bat Wing, showing the 3 regions to be identified.
19
20 B.- Once the Bat Wing Approach has been exposed (Fig. 13), we proceed to start the dis-
21 section of the upper compartment, detaching the entire periosteum of the glenoid cavity up
22 to the medial wall so that the meniscus is completely free. Similarly, this detachment is taken
23 to the lowest and medial part of the AT in its posterior portion (Fig. 14). The dissection will
24
have to reach to the wavy blue line (Fig. 15). We show how to perform the joint space dis-
25
26 section in the following video 1.
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29
30
31
32
33
34
35
36 (13) (14) (15)
37
38 Fig. 13. Deployment of the Bat Wing. Fig. 14. Dissection of the lowest part of the AT. Fig. 15. Depth of the
39 detachment of the periosteum.
40
41 Once the meniscus is completely freed from the upper compartment, we proceed to perform
42 the resection of the AT. It is important to do this at the level of the highest part of the top of
43 the glenoid cavity externally to do the marking. It is important to see the depth of the inter-
44 cranial middle fossa so that there is no communication with the dura mater. Do not do the
45 osteotomy using a chisel. Use a milling or ultrasound microtip, as may be seen in the follow-
46
47
ing video 2. You can see how the osteotomy is performed and the AT is removed in the
48 following sequence of images (Fig. 16).
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50
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52
53
54
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56
57 (16)
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Fig. 16. Resection of the AT.
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4 We show the objective of the surgery, which is the complete decompression of the entire
5 UJS. The degree of displacement of the disc does not matter; it does not have to be applied.
6
We can see the result in (Fig. 17). We show the complete TMJ decompression surgery. It is
7
8 sutured with monocryl 0000, preferably from the anterior part of the articular dissection to
9 the upper part of the EAC (Fig. 18).
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17
18
19
20
21
22
23 (17)
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25 Fig. 17. Complete liberation of the meniscus. Note all the space created, which will enable the meniscus to move
26 freely.
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38
39 (18)
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41 Fig. 18. Suture of the 5 cm approach, adding the two wings of the Bat Wing.
42
43
44
45 Proving Decompression.
46
47
Painful hypermobility with compression may be accompanied by complete dislocation or
48
49 very painful subluxation. The cuts of the CT with reconstruction, hypermobility with complete
50 dislocation on the left side and subluxation on the right may be appreciated. After the inter-
51 vention, the condylar displacement is the same, since the AT is not present, and complete
52 decompression of the UJS has been performed, so that the patient returns to normal, being
53 asymptomatic (Fig. 19a). Compression of the UJS is a very painful condition, being the main
54 cause of the joint pain. Note the increase of the UJS, in the sagittal view of UJS after the
55 intervention (Fig. 19b).
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10 (19a)
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12 Fig. 19a. Series of tomography’s in open mouth, maximum aperture with reconstruction of right and left, preoper-
13 ative and post-operative.
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15
16
17
18
19
20
21 (19b)
22 Fig. 19b. Preoperative sagittal section tomography, the post-operative showing the decompression in closed
23 mouth with UJS.
24
25 Hypomobility patients with painful compression of the UJS move their jaws forward when
26 the mouth is closed, because they feel relief with the jaw protruding, as may be appreciated
27
in the preoperative image (Fig. 20a). Note the space shown by the red arrow, as the jaw
28
29 moves forward. This is the space created by the conservative therapy based on guards. In
30 (Fig. 20b), the patient has had the intervention for decompression and resection of the AT,
31 and now has normal occlusion and is asymptomatic.
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33
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35
36
37
38
39
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41
42
43 (20a) (20b)
44
45 Fig. 20a. View of the CT with reconstruction, mouth closed, the patient moving the jaw forward. In Fig. 20b, the
46 view of the CT, mouth closed after decompression surgery of the UJS with removal of the AT, the MC assumes
47 its proper position.
48
49 Hypomobility is almost always painful, especially if the patient has gone for years with re-
50 duced movement of the TMJ. This impedes it from opening by at least 20 mm. In the follow-
51 ing sequence of CT with reconstruction, we show how with hypomobility the patient did not
52 displace the right condyle the same as the left before the intervention. After the decompres-
53 sion surgery the condylar positions improve notably, the MC takes its proper position, the
54 condylar positions being more symmetrical with mouth closed, as show in (Fig.21) The pain-
55
ful symptoms disappear.
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13 (21)
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Fig. 21. View of the lateral tomography’s at the extremes with reconstruction with mouth closed, preoperative
15 bilateral before decompression. Observe that on the right side, preoperative, the different position of the condyles
16 as shown by the blue arrow. In the post-operative central tomography, the condyles are almost symmetrical and
17 in a proper position of the condyles with respect to the GC.
18
19 In the following tomographic views, the results will be shown of the coronal view, as the
20 upper joint space is visibly reduced. In the coronal cut post-operative view, it may be seen
21
how the decompression was performed in its entirety. It may only be done by open surgery.
22
23 It shows a post-operative control 6 months after the intervention (Fig. 22a). In the preoper-
24 ative views of the sagittal section on the same patient, it can be appreciated in mouth open
25 how the condylar head is in close contact with the AT. In the post-operative view after de-
26 compression and arthroplasty of the AT, it can be appreciated that now there is no bone
27 contact between the structures (Fig. 22b). Once the bilateral decompression of the UJS and
28 the AT has been performed, the view shows in open mouth with reconstruction on the left
29 side the maximum preoperative opening; the MC is lodged in the infra-temporal fossa, caus-
30 ing condylar subluxation. Also note that after the arthroplasty of the MC, the opening is the
31
same as in the post-operative view (Fig.23).
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33
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36
37
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41 (22ª) (22)b
42
43 Fig. 22a. Coronal sections. Fig. 22b. Sagittal views.
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58 (23)
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60 Fig. 23. View with reconstruction pre- and post-operative open mouth.
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7 We present a hard-to-resolve case of luxation in the infra-temporal fossa in a patient in his
8
80s, who was not able to close his jaw for six months. The Bat Wing approach is an ideal
9
10 way to be able to have access to the temporo-zygomatic sutures. In the tomographic views
11 with preoperative reconstruction, the condylar head was lodged permanently in the infra-
12 temporal fossa. When the patient was like this for 6 months, the traction of the external
13 pterygoid muscles brought the condyles almost to the position of the temporo-zygomatic
14 suture. The post-operative tomography’s show how the right condyle returned almost to its
15 central position in the glenoid cavity, but not the left one, which remained in front of the
16 normal position. This is due to the prolonged time without closing the jaw, so that bilaminar
17 zone starts to occupy this space, a situation that occurs frequently among patients controlled
18
19
by occlusal guards for years, which moves the central condylar position in the glenoid cavity
20 forward (Fig. 24). The preoperative photos of the front and profile are shown, and we can
21 see the inability of closing the mouth. In the post-operatives, what is shown is that the patient
22 can displace his jaw and close his mouth (Fig. 25).
23
24
25
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35
36 (24)
37
38 Fig. 24. Pre- and post-operative tomography’s.
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45
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47
48
49 (25)
50
51 Fig. 25. Pre- and post-operative photos.
52
53 We present an alternative treatment for cases with widespread destruction of the condylar
54 head: the application of a product based on hydroxyapatite (HA) (tetracalcium phosphate
55 and alpha tricalcium phosphate-alpha). It is a cement commonly used in neurosurgery for
56 spine surgery. It is basically bone replacement. We have only had 1 patient, and it has been
57 a year since the surgery. The images show extensive damage on the patient with complex
58
59
anxiety. The patient was treated with surgery previously, which caused major damage to the
60 condylar head (Fig. 26). The coronal section tomography is shown with placement of the
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2
3
4 surgical cement. The patient presented a lot of pain on the 9-point visual analog scale (VAS)
5 but has been asymptomatic since the intervention. Note: We cannot be guaranteeing an
6
effective result, given that the sample is only one patient.
7
8
9
10
11
12
13
14
15
16
(26)
17
18 Fig. 26. Preoperative coronal tomography. Note the severe damage to the condylar head. In the following post-
19 operative view of the coronal tomography the HA surgical cement can be seen. In the view of the Bat Wing
20 approach, the condyle with the HA is in place, molded and adapted to the condylar surface.
21
22
23 Statistics.
24 84 decompression patients were operated on over 7 years, 81 women and 3 men. The
25 treatment was decompression of the UJS and arthroplasty of the AT. The UJS surgery was
26 performed on 72 patients, and 12 patients from the lower articular space (LAS). Post-oper-
27 ative clicking occurred in 26 patients. Follow-up was for an average of 4 years, with a result
28
29 that left 94% of the patients completely asymptomatic (Fig. 27). The articular decompression
30 technique was implemented in 2013, the year that fewer patients were operated on. In 2019,
31 17 patients were operated on, as can be seen in (Fig. 28).
32
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42 (27)
43
Fig. 27. A table of results on 84 patients, with 165 open temporo-mandibular joints
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59 (28)
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4 Fig. 28. A 3D graph showing the year-to-year breakdown of the 84 patients treated with decompression of the
5 TMJ.
6
7
8 Discussion.
9
10 We can say that exploratory and corrective arthroscopy, presented by some authors, is not
11 enough to achieve decompression of the EAS, because extensive manipulation of the entire
12 EAS is required, especially in the entire Medial Wall of the Glenoid Cavity (PMCG ), impos-
13 sible to release arthroscopically. It is true that TA arthroplasty can be achieved arthroscopi-
14 cally, it is also true that complete release of the EAS and the creation of the new superior
15
articular space cannot be verified by this route, when performing the eminectomy as shown
16
17 in the video, it is you have to check under direct vision the condylar movement and the disc.
18 Regarding arthrocentesis, it is materially impossible to decompress the EAS by means of
19 the infiltration of physiological solution into the EAS. Once a few days have passed after
20 arthrocentesis, the amount of physiological solution deposited in the EAS will disappear and
21 the patient will be back with the same painful symptoms.
22
23 Condylar meniscus plication and Mitek system plication [5] is a fairly distorted idea of reality,
24 especially they NEVER DEMONSTRATE, the correct position of the meniscus-condyle re-
25
26
lationship and its permanence over time, that the procedure is effective. Nor is there a follow-
27 up to ensure that patients remain asymptomatic by the authors, they put images of a MRI
28 without demonstrating the correct new position of the disc at 12 o'clock with respect to the
29 condylar zenith.
30 We demonstrate extensively in the tomographic images over time as the EAS, decompres-
31 sion remains, which is the basis of the main treatment in internal TMJ disorders.
32
33
34 Conclusions.
35
36 The main objective of this work was the evaluation and verification of the decompression
37 procedure of the EAS, by means of the resection of the articular eminence, completely free-
38
39
ing the articular disc and restoring the EAS, a situation that is not resolved with an arthro-
40 scopic procedure and arthroscopy.
41
42
Displacement with and without reduction of the disc in any direction is not re-effective as
43
44 long as there is no presence of pain for treatment purposes. The main objective of decom-
45 pressive surgery is to eliminate pain. When performing the eminectomy, the function of the
46 meniscus or AC is not affected, and the patient is not dislocated, therefore the patient will
47 obtain permanent pain relief. In our experience with 84 cases operated with decompressive
48 open surgery of the EAS with TA arthroplasty, we achieved an effective treatment of 94% to
49 leave patients totally asymptomatic of chronic TMJ pain.
50
51 Nomenclature List.
52
53
54 AC- Articular capsule.
55 AM- Articular meniscus.
56 AN- Auriculotemporal nerve.
57 AT- Articular tubercle.
58 ATE- Articular tubercle eminectomy.
59 ATS- Artery temporal superficial.
60 EAC- External auditory canal.
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4 GC- Glenoid cavity.
5 HA- Hydroxyapatite.
6
IDTMJ- Internal disorders of the temporo-mandibular joint.
7
8 LAS- Lower articular space.
9 MC- Mandibular condyle.
10 MRI- Magnetic resonance imaging.
11 TMJ- Temporo mandibular joint.
12 TPF- Temporoparietal fascia.
13 UJS- Upper joint space.
14
15
16
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