TMJ Replacement

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Preoperative Considerations

Consent:

Anesthesia/Positioning:

Other:

Armamentarium:

Technique

Postoperative Considerations

Immediate:

Follow Up:

Operative Note

Surgeon:

Assistant surgeon:

Assistant at Surgery:

Preoperative Diagnosis:

Ankylosis left TMJ (M26.61)

Ankylosis right TMJ (M26.61)

Internal derangement left TMJ (M26.60)

Internal derangement right TMJ (M26.60)

Severe osteoarthritis left TMJ (M26.69)

Severe osteoarthritis right TMJ (M26.69)

Postoperative Diagnosis:

Same

Procedure:

Right custom total temporomandibular joint replacement - 21243

Left custom total temporomandibular joint replacement – 21243

Bilateral custom total temporomandibular joint replacement – 21243B

Abdominal fat graft - 15769

Implants: TMJ Concepts custom prosthetic joint with fixation screws

Specimen: None

EBL: ***

Complications: None

Findings:

Indications: The patient was comprehensively evaluated preoperatively for degenerative TMJ symptoms.  After failing more conservative measures, the severity of joint disease necessitated joint replacement.

The patient presented preoperatively. Informed consent was verified and any questions were invited and answered after reviewing risks and benefits to the procedure. The patient was then transferred to the operating room and onto the operating room table without issues. All appropriate monitors were attached and verified to be working correctly. The patient then underwent nasal endotracheal intubation without complication. End-tidal CO2 as well as bilateral breath sounds were verified. The tube was then secured by the surgical team. 10mL Lidocaine 1% with 1:100,000 epinephrine was injected into the maxillary and mandibular vestibule. Next, Stryker Hybrid arch bars were placed on the maxilla and mandible. The patient was then prepped and draped in standard sterile fashion.

First, attention was directed at the left side. Standard preauricular and modified submandibular incision were marked with a marking pen. Lidocaine with epinephrine was delivered via local infiltration in both incision sites. Attention was then directed at the preauricular incision. A #15 blade was used to incise through skin. Dissection was then bluntly carried down to the level of the temporalis fascia. A vertical incision through the temporalis fascia onto the zygomatic arch was made. Subperiosteal dissection was carried anteriorly along the zygomatic arch, exposing the articular eminence. Inferior blunt dissection was performed using a #9 periosteal elevator to fully expose the lateral capsule of the TMJ. Next, the superior joint space was entered using tenotomy scissors. A freer elevator was placed into the joint space. The disc and condyle were retracted inferiorly a #15 blade was used to finish the incision of the capsule along the zygomatic arch. Bovie electrocautery was then used to create a vertical incision through the disc exposing the degenerative condyle. Subperiosteal dissection was performed as around the condyle and neck of the mandible inferiorly and then the wound was then packed with moist gauze.

Next attention was directed to the submandibular incision. A #15 blade was used to incise through skin and blunt dissection was performed down to the level of platysma. Blunt dissection was continued to the inferior border of the mandible using nerve stimulation. The marginal mandibular nerve was identified and protected. Once the pterygomasseteric sling was identified the area was tested with the nerve stimulator and sharp incision was performed down to the mandible. Subperiosteal dissection was carried along the lateral ramus connecting superiorly to the preauricular incision. Next, the condyle was removed using a sagittal saw under irrigation according to the plan. The wound was packed and both wounds were covered with sterile dressing.

Next, attention was directed at the right side. Standard preauricular and modified submandibular incision were marked with a marking pen. Lidocaine with epinephrine was delivered via local infiltration in both incision sites. Attention was then directed at the preauricular incision. A #15 blade was used to incise through skin. Dissection was then bluntly carried down to the level of the temporalis fascia. A vertical incision through the temporalis fascia onto the zygomatic arch was made. Subperiosteal dissection was carried anteriorly along the zygomatic arch, exposing the articular eminence. Inferior blunt dissection was performed using a #9 periosteal elevator to fully expose the lateral capsule of the TMJ. Next, the superior joint space was entered using tenotomy scissors. A freer elevator was placed into the joint space. The disc and condyle were retracted inferiorly a #15 blade was used to finish the incision of the capsule along the zygomatic arch. Bovie electrocautery was then used to create a vertical incision through the disc exposing the degenerative condyle. Subperiosteal dissection was performed as around the condyle and neck of the mandible inferiorly and then the wound was then packed with moist gauze.

Next attention was directed to the submandibular incision. A #15 blade was used to incise through skin and blunt dissection was performed down to the level of platysma. Blunt dissection was continued to the inferior border of the mandible using nerve stimulation. The marginal mandibular nerve was identified and protected. Once the pterygomasseteric sling was identified the area was tested with the nerve stimulator and sharp incision was performed down to the mandible. Subperiosteal dissection was carried along the lateral ramus connecting superiorly to the preauricular incision. Next, the condyle was removed using a sagittal saw under irrigation according to the plan. The wound was packed and both wounds were covered with sterile dressing.

A new drape was placed over the patient and the small hole created adjacent to the patient's mouth. The patient was then placed into MMF using stainless steel wires and rubber bands using the Hybrid Arch bars. Once finished, telfa was placed between the arch bars and the lips to protect them. A sterile Tegaderm was placed over the mouth and the drape was removed.

The surgeons re-scrubbed and gowned. Next, the patient was re-prepped and re-draped. Attention was directed again at the left side. We then removed the packings from both skin wounds and hemostasis was noted. The articular disk and retrodiscal tissue was removed at this point. The fossa component of the TMJ concepts prosthesis was then placed passively onto the zygomatic arch, articular eminence and fossa and held in position with a seating tool. It was secured to the arch with 6mm and 8mm screws, which were drilled under copious saline irrigation. Next the condyle was then inserted along the lateral ramus such that the condyle was seated in the most superior and posterior position of the fossa. The prosthesis sat passively against the lateral ramus of mandible. Screws were placed per the TMJ concepts map under irrigation. The site was irrigated copiously with normal saline hemostasis was noted. We then injected floseal into the wound. The On-Q pain pump was passed through an introducer adjacent to the submandibular incision into the preauricular region. The catheter was closed into the wound and held in place with 5-0 nylon ×4. Both wounds were closed in a layered fashion. The pre-auricular incision was closed with 3-0 vicryl and 5-0 fast gut for the skin. The submandibular incision was closed with 3-0 vicryl, and a 4-0 monocryl subcuticular suture.

Attention was then directed at the right side. The packings from both skin wounds were removed and hemostasis was noted. The articular disk and retrodiscal tissue was removed at this point. The fossa component of the TMJ concepts prosthesis was then placed passively onto the zygomatic arch, articular eminence and fossa and held in position with a seating tool. It was secured to the arch with 6mm and 8mm screws, which were drilled under copious saline irrigation. Next the condyle was then inserted along the lateral ramus such that the condyle was seated in the most superior and posterior position of the fossa. The prosthesis sat passively against the lateral ramus of mandible. Screws were placed per the TMJ concepts map under irrigation. The site was irrigated copiously with normal saline hemostasis was noted. We then injected floseal into the wound. The On-Q pain pump was passed through an introducer adjacent to the submandibular incision into the preauricular region. The catheter was closed into the wound and held in place with 5-0 nylon ×4. Both wounds were closed in a layered fashion. The pre-auricular incision was closed with 3-0 vicryl and 5-0 fast gut for the skin. The submandibular incision was closed with 3-0 vicryl, and a 4-0 Monocryl subcuticular suture.

The patient’s mouth was then opened to remove MMF and the occlusion was found to be stable and repeatable. The arch bars were then removed. Tegaderms were then removed from the eyes and BSS placed in both of them to wash them free of the lacrilube.  The patient was wiped down with a moist lap and then turned over to the anesthesia team where the patient was awakened from general anesthesia and extubated without complication and returned to the PACU for recovery in stable condition.

Coding

Diagnosis Codes

  • Ankylosis left TMJ (M26.61)Ankylosis right TMJ (M26.61)
  • Internal derangement left TMJ (M26.60)
  • Internal derangement right TMJ (M26.60)
  • Severe osteoarthritis left TMJ (M26.69)Severe osteoarthritis right TMJ (M26.69)

Procedure Codes

  • Right custom total temporomandibular joint replacement - 21243
  • Left custom total temporomandibular joint replacement – 21243
  • Bilateral custom total temporomandibular joint replacement – 21243B
  • Abdominal fat graft - 15769

Forms

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