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Bilateral TMJ Arthroplasty / Mandibular Coronoidectomy / Maxillomandibular Fixation Transcribed Operative Sample Report


PREOPERATIVE DIAGNOSIS:  Bilateral degenerative disease affecting mandibular condyles, temporomandibular joint.

POSTOPERATIVE DIAGNOSES:  Degenerative joint disease involving bilateral condyles, mandible, with heterotopic bone formation and fibrous ankylosis.

1.  Bilateral temporomandibular joint arthroplasty. 
2.  Bilateral mandibular coronoidectomy.
3.  Application of maxillomandibular fixation using Ivy loop wires and elastic traction.

SURGEON:  John Doe, MD

ANESTHESIA:  General via nasal intubation.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite, and following administration of a general anesthetic utilizing nasotracheal intubation, the patient was prepared and draped in a manner appropriate for extraoral surgical reconstruction of the jaws. Intraoral procedure was started by placement of Ivy loop 25 gauge wires about the maxillary and mandibular teeth for intraoperative surgical traction. Elastic bands will be placed at the mid point of the operation. In the patient's left lower abdomen, in the outer aspect of the lower quadrant, a 2 cm incision was made through the skin entering into the subcutaneous tissues and approximately 5 to 6 mL of subcutaneous fat tissue was harvested for later use. This tissue was placed in saline-soaked gauze and the incision was checked for hemostasis and then closed utilizing 3-0 Vicryl suture and skin staples. A Tegaderm dressing was placed and then attention was directed to the jaw areas. 

The patient was re-prepared and draped in a manner appropriate for external approach to the mandible. The patient's head was turned to the left side and local anesthesia of 0.25% Marcaine with epinephrine was infiltrated into the preauricular area of the face overlying the temporomandibular joint and along the inferior border of the jaw in the angle area for hemostasis and pain control. A preauricular incision utilizing a previously made skin closure was accomplished as well as a modified Risdon incision, which was approximately 2.5 cm in length. Both incisions were carried down through the skin and subcutaneous tissue until the fascia plane was encountered. In the Risdon incision, the fascia was dissected, paying attention to preserve nerve tissue that may be in the area and retracting the mandibular branch of the facial nerve inferiorly away from the incision line. Once the masseter-pterygoid sling was encountered, this was exposed and incised sharply at the angle and the masseter muscle was reflected from the lateral aspect of the mandible. The preauricular incision was carried down until reaching the lateral aspect of the joint capsule. This later was easily determined because the underlying metallic fossa eminence implant was visible through the overlying fascial tissue.

Staying in this plane, dissection was carried inferiorly approximately 1 to 1.5 cm, thereby allowing good visualization of the lateral aspect of the temporomandibular joint capsule. The joint capsule itself was infiltrated with the local anesthetic solution and then sharply incised horizontally entering into what remained of the joint space. Significant scar tissue had formed as well as a fair degree of heterotopic bone on the medial aspect of the residual portion of the condyle. The condyle was grossly deformed and flattened and heterotopic bone, approximately 1 cm AP x 5 to 7 mm medially, was encountered that was firmly fibrosed to the medial connective tissues. The condyle could not be manipulated within the glenoid fossa until the adhesive quality of this heterotopic bone was released. Using direct visualization and micro reciprocating saws, a coronoidectomy of the right mandible was accomplished and the specimen placed aside. The condyle was also removed using the micro reciprocating saw as previously determined by 3-dimensional model reconstructive surgery. After the condyle was resected, the glenoid fossa was inspected. The implant previously placed a number of years ago was stable. A layer of bone had started to creep across from the medial aspect. This was debrided and hemostasis of the surgical site was accomplished. Sponge dressings were placed within the two incisions and the patient's head was then turned to the right side, exposing the patient's left side. Similar incisions were made and coronoidectomy and condylectomy were accomplished. A similar finding of heterotopic bone on the medial aspect of the remaining portion of condyle was also visualized. Both specimens were to be submitted and photographed. 

After completion of the bilateral condylectomy, arthroplasty and coronoidectomy, the patient's mandible was placed into a normal occlusion related to the maxilla. Direct fixation was accomplished using elastic traction across the numerous maxillary and mandibular Ivy loop wires. After traction was applied, the patient's head was turned to the left side and the prosthetic condyle was placed into the incision directly against the fossa eminence implant and stabilized using one screw at the bottom of the device. The same procedure was carried out on the patient's left side. With the patient's two prosthetic devices initially stabilized, the mandible was checked for reasonable occlusion. Such was found to be in existence and the traction which had been removed was replaced. The additional six screws were placed to rigidly stabilize each of the prosthetic devices and all screws were tightened by hand without stripping of any of the screw holes or the screws themselves. Good rigid fixation of both condyle prosthetic devices was found to be present. The previously harvested abdominal fat at this time was divided into two parts and this fat was then placed into the space around the prosthesis and within the confines of the overlying fascial covering and joint capsule. Obliteration of the residual joint space was accomplished and also agent preventing scar formation about the device.

After the fat grafts were placed bilaterally, deeper wound closure was accomplished utilizing interrupted 3-0 chromic sutures as well as subcutaneous closure and then running 6-0 nylon sutures were used for the skin closures. After closure of all four incisions, the patient's occlusion was checked and found to be as predicted. Two elastic bands remained between the maxillary and mandible on each side. The patient's fascial area incisions and area was cleansed. These incisions were dried and then Mastisol and Steri-Strip dressings were placed on both incisions on each side of the face. After wound closure and dressing, the patient was awakened. The patient was extubated and taken to the recovery room in a reactive, responsive condition. The patient tolerated the procedure without complications. Estimated blood loss was 200 mL. The patient was taken to the recovery room and will be admitted for observation.