Description: Temporomandibular joint (TMJ) surgical procedures include both open and closed surgical techniques.

TMJ arthrotomy involves a preauricular, postauricular, or endaural incision to gain access to the joint compartment. It usually is performed for severe fibrous adhesion removal in the TMJ, bony or fibrous ankylosis, tumor resection, chronic dislocation, painful nonreducing disc dislocation, and severe osteoarthritis. Open TMJ surgery may range from discoplasty; discectomy; arthroplasty; and/or eminoplasty (reshaping of articular eminentia) to optimize the fit of the disc, condyle, and fossa; to total joint replacement utilizing costochondral grafts or vitallium metal implants. For the open treatment of condylar fractures, extraoral approaches (e.g., preauricular, retromandibular, and submandibular) are used. All extraoral approaches to the TMJ have the risks of facial nerve damage and the creation of visible scars. Due to those possible complications, endoscopically assisted transoral approaches for open reduction and miniplate fixation of condylar mandible fractures are used increasingly more often.

TMJ arthroscopy is a minimally invasive technique that has reduced the need for open surgery of the TMJ. Arthroscopic TMJ surgery is indicated for treatment of internal derangements and intracapsular disorders. The major advantage is that it results in less periarticular tissue disruption and better preservation of vascular supply and lymphatic drainage of the joint. The procedure involves insertion of a TMJ miniscope through a preauricular puncture on the canthus-tragus line and insertion of an outflow needle. The joint compartment is continually lavaged with LR. A second cannula can be inserted. Arthroscopic procedures are performed using a triangulation technique. Arthroscopic TMJ procedures include lysis of adhesions and lavage, partial synovectomy, and abrasion arthroplasty. Sometimes a holmium:YAG laser is used to make intraarticular incisions anterior to displaced discs and to treat inflamed synovial tissue. Usually, at the end of the procedure, 2 mg dexamethasone is injected into the joint space. Injection of 2 mL 0.5% bupivacaine mixed with 1 mL sterile saline solution has been shown to significantly reduce postop pain. Arrhythmia, reflex bradycardia, and pulmonary edema have been reported as general complications in TMJ arthroscopy.

Usual preop diagnosis: Internal derangement, subluxation, and ankylosis of TMJ

See Anesthetic Considerations for Dental/Oral Surgery, p. 274.

Description: The most common surgeries of the oral cavity are third-molar removal, surgical extractions, apicoectomies, orthodontic exposures of teeth, osseointegrated implants, bone grafting, treatment of oral pathologic conditions, and preprosthetic surgery. Surgical extractions of teeth involve intraoral exposure of the roots through a mucosal incision and removal of overlying bone with a surgical drill. Risks associated with removal of teeth in the mandible are damage to the inferior alveolar nerve (anesthetic numb lip), lingual nerve (anesthetic numb tongue), and, rarely, mandibular fracture. In the posterior maxilla, oroantral fistulas can occur and are closed with a mucoperiosteal flap. Exposure of teeth for orthodontic therapy involves creation of a mucoperiosteal flap and attachment of a bracket with a small gold chain on which the orthodontist can pull to integrate the tooth into the dental arch. Bone grafting to the maxilla and mandible is done for augmentation of the atrophied alveolar ridge and the maxillary sinus and in cases of cleft lip and palate. A second team usually harvests the bone at the same time. Possible extraoral harvesting sites include the anterior or posterior iliac crest, the tibia, and the skull. Preprosthetic surgery of the oral soft tissue in preparation for dentures has been replaced largely by insertion of osseointegrated implants for retention of individual teeth and dentures. Surgical treatment of oral pathology can range from removal of dentigerous cysts, with and without bone graft, to laser or surgical removal of mucosal lesions.