A METHOD OF MOBILIZING THE TEMPOROMANDIBULAR JOINT

¹ Department of Bone and Joint Surgery, Northwestern University Medical School; Wesley Memorial and Cook County Hospitals, Chicago

A method has been propounded for mobilization of an ankylosed or interlocked temporomandibular joint. It consists of two basic tenets: (1) resection of the articular ends of bones and (2) skeletal traction. For surgical mobilization of the mandible, it is important that the incision should avoid the larger blood vessels and the upper branches of the facial nerve; that tine temporomandibular joint be approached from above and back, downward and forward subperiosteally, under the temporalis and through the base of the articular tubercle of the temporal bone; that a wide segment of bone be resected from around the joint, mostly from the mandible, so as to create a space; and that the cavity excavated be packed by some material which will prevent seepage and hematoma and keep the raw surfaces of bone from coming together and reuniting. Oxycel gauze is both hemostatic and slowly absorbable, and has been shown to counteract proliferation of bone; it is well suited for use as a pack. If possible, the cavity created should not communicate with the ear. If the external acoustic meatus has been perforated inadvertently, it is best not to suture the rent, but rather to pack the ear canal up to the tympanic membrane with a wick of oxycel gauze.

The pattern of bone resection in and around the temporomandibular joint admits of several variations:

1. When the articular condyle has become firmly fused to the temporal bone, resection of a segment from the ramus farther down is deemed safer than gouging the condyle out of its solid matrix at the base of the skull.

2. In pyogenic arthritis, caused by extension of infection from the middle ear, more bone is chiseled off the posterior border of the ramus in order to gain a wider space between the mandible in front and the tympanic plate behind.

3. In congenital synosteosis between the mandible and the maxilla, more bone is excised from the anterior border of the ramus.

Skeletal traction through the mandible is considered beneficial for injuries to the temporomandibular joint and after operation. It is suggested that, in some fractures and dislocations of the articular condyles and in comminuted depressed fractures of the zygomatic arch, the timely institution of skeletal traction will prevent the fixation of the jaw which often follows these injuries. After surgical mobilization of the mandible, skeletal traction through the chin is regarded as expedient; it has many advantages over the old-fashioned wedge or mouth gag, which exerts only static pressure against the teeth. The stress caused by skeletal traction is dynamic, and the pin through the mandible is well tolerated. Skeletal traction augments the space created by excision of bone; it keeps the raw surfaces of bone apart, and aids the muscles of mastication to contract against tension and regain their strength. Moreover, when both temporomandibular joints are subjected to resection and the muscles of mastication are weak, as they invariably are in long-standing immobility of the mandible, the jaw drops toward the throat and makes breathing difficult. The loosened mandible must be lifted away from the throat and held up by skeletal traction.

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