Transcribed by Joseph Schwimmer

Craniofacial Biology Lecture #43 - CCP 6 - TMJ Dysfunction 5/13/14

Slide 1 Introduction
Dr. Marci H. Levine Good morning everyone, Im Dr. Levine. I am full time in the department of oral
and maxillofacial surgery. I am also the course director for the D@ course, so I will be interacting with
you very shortly when you become D2 students, and Im also the faculty advisor for the oral surgery
society, which is a student interest group for people in the school who are interested in oral surgery.
So today what id like to talk about is a series of cases related to the TMJ. As Dr. Wishe mentioned, Dr.
Sirois works in our faculty practice, as do I and a bunch of oral surgeons. Although Dr. Sirois is primarily
related in the medical management for orofacial pain. As oral surgeons, were typically involved in the
surgical side.
Slide 2 Objectives
So what id like to show you today is a series of cases that relate to TMJ disease, or TMD. My only
request is that you hold your questions till the end. I have a lot of cases which id like to get to in about
40 minutes. So well have some time as soon as im finished to answer all of your questions, and if you
wanna come up and ask me privately at the end thats totally fine. These slides are posted on NYU
Classes, so theres very little that you need to take notes for. Today were gonna talk about some basic
principles, primarily related to ankylosis what that is. Reconstruction, as it relates to the TMJ. Facial
fracture repair, because as oral surgeons were often asked to repair fracture, specifically of the condyle,
and other aspects of the joint. And then, some interesting findings of joint pathology.
Slide 3 Case 1
So as surgeons, were typically trained in a case-based method. And youll see in D2 that a lot of the
teaching well do in oral surgery is related to patient cases. I think it makes the information a little bit
more interesting to understand. And if you can relate it to an actual person, its a little bit more relevant
to what youre studying. So case #1, these are actual patients. Not all of them are treated by me but
theyre all treated by our department. So a 16 year old female patient presents to our office for difficulty
opening her mouth. The patient tells us that she fell approximately 3 years ago from about 6 stories,
thats pretty high. She also had bilateral mandibular fractures, meaning that she fractured her jaw. The
mandibular body is part of the lower jaw that contains the teeth. And she also fractured the condyles,
where the TMJ slides on the right and on the left. This happened 3 years ago. So she was treated for her
fractures and now she comes back to the oral surgeon saying I can only open my mouth 5mm, really
really small. So just for your own reference, what is a normal maximum incisal opening? Take a guess,
whats the normal amount? 35-40mm. So why does it matter? What are the implications of somebody
opening only about 5mm? Makes it hard to d0 what? Makes it hard to eat, hard to speak, and hard to
maintain hygiene. You need about 30mm to even fit a toothbrush in. so imagine, its difficult for her to
clean her teeth.
Slide 4 Presentation
When you take a look at her, this is what she looks like, and the picture on the left is her holding her jaw
apart. Thats all she can open. She tries to open a little bit more, and it just wont go. It feels like the jaw
is stuck.
Slide 5 - Panorex
So as oral surgeons we do a clinical exam, we take a look at her extraorally and intraorally, we look
inside her mouth, and then we take an x-ray. And this is an x-ray thats called a panorex, also called a
panoramic. If youve ever had your wisdom evaluated, your dentist or your oral surgeon probably took
an x-ray like this, because it lets us see a lot of the structures of the head and the neck. So in this case,
were primarily focused on the TMJ region. And this patient had had fractures of her condyles on both
sides. So just remember in your mind what her condyles look like. Theyre very very short, its hard to
see the separation between the condyle and the base of the skull.
Slide 6 Normal Panorex
This is what a normal panorex looks like. And theres a distinct difference between the fossa or the base
of skull, and the condyle. So lets go back (previous slide). Can you see how blurry that is, and the head
of the condyle looks very malshapen.
Slide 7 3D CT Scan
This patient has ankylosis, and Ill describe what that means. As part of our workup we also took a CT
scan, a cat scan in order to look at the patient from 3 dimensions. Part of the computer imaging allow us
to build models, so we can hold the models in ur hands, and look from all directions what the patient
looks like. And these are the pictures that that created. Ankylosis refers to the fusion of the condylar
head to the base of the skull. So in essence her jaw is fused, its locked permanently until she has some
sort of surgical intervention, and thats from her fracture. So thats what that looks like on her right side,
and thats what it looks like on her left. And because she had fractures on both sides, both sides are
what we called ankylosed. And Ill talk about what that means.
Slide 8 3D CT Scan
This is the picture where if she would have her chin up to the sky, and youre looking underneath her. So
as though her feet are at you and youre looking up, this is her chin up here, these are her zygomatic
arches, this is the mandible. And its fused, again, in the condylar region on both sides. So this patient
has a serious problem, and this is something that has to be managed surgically.
Slide 9 Trismus
So this patient has trismus. When someone has a significant reduction in maximum incisal opening, the
definition is trismus. Trismus comes from the Greek word trismos, it relates to any restriction in mouth
opening. The reason why she has trismus, is from ankylosis, from her fractures healing abnormally, but it
can happen from almost any reason. Odontogenic means related to a tooth. So if someone had a
severely infected wisdom tooth and was very swollen, the patient would probably have trismus from all
the swelling in the way. The pterygomasseteric sling wouldnt function properly and the patient cant
really open. Could be related some other type of infection. Her etiology was trauma. Neoplastic means
some sort of tumor. So if you had a growth in the TMJ or something in the joint opening apparatus that
may inhibit your opening. Some psychiatric disorders like severe hysteria, where someone has severe
tonic clonic contractions of the muscles, may relate to trismus. And some patients are actually born this
way, where we have to do procedures on neonates because they cant feed properly.
Slide 10 Ankylosis
So her primary diagnosis is ankylosis. And ankylosis as I said refers to fusions of the condyle to the joint
space, or the glenoid fossa. Patients who have ankylosis have trismus by definition, because they cant
open their mouth any more than normal, and we said normal is about 35-40mm. you can have trismus
on one side, if its on one side you can imagine that he opposite side thats normal is working, but the
jaw is constantly pulled towards the affected side, the abnormal side. Because the jaw cant function
equally on both sides. So how does bilateral ankylosis present? This patient has it on both sides. It
presents with severe restriction on opening in general. It can often be due to bony attachments or
fibrous soft tissue attachments. So what that means is when the bone tries to heal itself after injury, like
her fractures, theres a lot of blood in the joint space. The joint space is very vascularized, so theres a lot
of vessels that can be torn and sheared and they can bleed. Unfortunately that blood often leads to
heterotopic bone formation. So if the condylar fractures are not treated appropriately and Ill show you
how we do that, then they can fuse. And they can either use with really thick soft tissue which is fibrous
soft tissue, or it can turn into rock hardbone. And this patient had bone.
Slide 11 Ankylosis
Ankylosis can happen in different locations, it can happen as in this patient which is intracapsuular,
which is inside the joint. It can happen outside the joint, so if someone has a tumor, someone has an
infection, it can spread, can be due to neoplastic reasons, or again, infectious reasons. And infections
such as middle ear infections, especially in third world countries where they dont have access to
antibiotics, can lead to ankylosis in children. Its often more common in kids because the condyle has a
growth center. So ankylosis is very very common in children who are still development. And its a worry,
because if we dont treat the ankylosis then you could imagine the facial structure will be changed. As
patients grow and develop their chin may be deviated to one side. The muscles may be underdeveloped.
Patients may be malnourished. So it can have an effect on the entire body.
Slide 12 Intercapsular
So again, this patient would have what we would define as trismus due to intracapsular ankylosis. And
she had a fusion of the actual condyle, the disc, and the fossa. And Ill show you pictures of her
operation so you can see how we treat this. Its most commonly due to trauma. She has severe
restriction of opening. She had no deviation because it was on both sides. And her condysurfcaes looked
irregular. So again, our patient had bilateral condylar fractures.
Slide 13 X-ray
This is a picture of a plate and screws that was used where she had her fracture of the mandubluar
body. So she had 3 fractures. One of the condyle on the right, one on the left, and then one of the
mandible in the middle.

Slide 14 - Extracapsular
Just a couple of words about other types of ankylosis, it can often be extracapsular. This can be due to
fractures elsewhere in the head and neck, particularly a zygomatic arch fracture, because the zygomatic
arch once its broken in this area can directly impinge on the coronoid and the condyle, and again can
directly impinge onto someones opening.
Slide 15 - Neoplasia
Tumors or cancers of the TMJ are very rare, but its always on the differential diagnosis, especially in an
older patient. So if you were to see an older patient in the clinic who has a severe restriction of mouth
opening, you wanna ask some basic questions. Have you ever had a history of cancer? Anyone in your
family? Any risk factor? Heavy smoker, alcohol use, things like that. Chondrosarcoma is the thing that
comes to mind. Chondro, because its cartilage related. And the TMJ is rich as you know in the
cartilaginous surface.
Slide 16 Infections
And then finally infections and I mentioned middle ear infections. Again often in countries that dont
have access to amoxicillin or basic antibiotics, children can have middle ear infections that can be
devastating in the sense that it can lead to blood spread or hemotogenous spread of the infectious
microbacteria, directly to the joint because the middle ear is right in front, and patients can present with
ankylosis. So what advances in modern medicine can account for this? Antibiotics.
Slide 17 Goals
So as the oral surgeon, we often treat patients who have ankylosis because it requires surgical
technique. And our job is #1 to identify the cause. If I cant figure out why it happens, then its hard to
figure out what to do. Obviously, wed treat an infection very differently than you would treat
congenital ankylosis or bilateral fractures. We then do a procedure to remove whatever the obstruction
is to opening, to remove the ankylotic mass. And then we do joint reconstruction. One of our main goals
is to restore MIO, or the maximum incisal opening. Because we want to make sure the patient can eat,
speak, maintain oral hygiene, normal bodily functions. And we want patients to be able to function
without pain. Thats a goal. And the last question we already answered. Patients need to able to open
about 30mm for comprehensive dental care. Your fingers are about 10mm on average, so about 3 or 4,
my hands are a little bit smaller so maybe 4. But part of your exam should be asking your patient how
widely can you open and documenting that. Because its very important to make sure that patients have
a normal opening.
Slide 18 Case
Alright, so I have to remind you the pictures are a little bloody, but as surgeons obviously we like that, so
this will wake you up. So one common way to approach the TMJ is to do whats called a bicoronal
incision. You can imagine the joints are on the outside of the mouth, theyre close to the skin, and it can
be hard to do a procedure in the mouth to get to them. You can. Sometimes we do that especially if
were doing jaw corrective surgery. But often times its much easier to do it this way. So we literally
under general anesthesia, patient is asleep in the hospital make an incision from the ear over the scalp
to the ear on the opposite side. And as oral surgeons were trained to do this. We then pull down all the
muscles and the nerves and the vessels. Youre making faces, very interesting. And we pull it down over
the front so that we can get to the joint space on both sides.
Slide 19 Bicoronal
So thats what this patient had. So thats called a bicoronal approach. Bicoronal, coronal means head, bi,
bilateral. So she had a bicoronal approach to the joint, and what we do shes obviously asleep so
theres no pain so we make an incision right thorough the hairline we go through the scalp, and then
using sharp instruments, we dissect down to the joint.
Slide 20
Keep going and keep going, this is an artery, so theres very little blood, but were starting to come down
this is where her ear is, and her nose is over here and her feet are somewhere off the field.
Slide 21
And look what we find, were coming down, going through the vessels, through he muscles, through the
arteries, and we come upon an ankylotic mass. So its literally a huge ball of bone thats locked, and
thats why she cant function and open normally. So we find the ankylotic mass. Again, this is her ear, so
her nose is somewhere over here, and we identify where the big block of bone is.
Slide 22
We then go to the opposite side and do the exact same thing. So we make an incision. Theres a little
piece of gauze in her ear so the blood doesnt go inside. We dissect, this is fat, underneath the scalp.
Slide 23
We go through the layers one by one. Because remember the facial lives through the parotid gland right
in front of the ear, so we dont wanna damage that. And again we fine a huge ball of bone, or ankylotic
mass.
Slide 24
And again, this is what that looks like. So one of the goals to restore her function is to remove the
obstruction to opening.
Slide 25 Resection
So we literally cut it out. And this is what it looks like on one side. So by using osteotomes like cleavers,
special instruments, drills, sort of like orthopedic surgery on a much smaller scale. We have very similar
instruments, we have a saw, we have a bur, and we literally slice off that piece of bone.
Slide 26 TMJ Reconstruction
So now that weve taken out the ankylotic mass, she can literally open and close her mouth because
weve removed the obstruction to function. But the second function of the procedure is reconstruction.
So we have to repair to TMJ because we want to give her normal anatomy. We want to be able to
ensure normal motion, meaning up and down, side to side, we want to be able to have her function in a
normal way. I'm going to show you some of the options that we have for reconstruction. And we'll talk
about how we decide what to do.
Slide 27 Total Joint Replacement
So patients often come to the oral surgeon having their joints replaced, or having their joints
reconstructed, when they have a lot of pain, when they have a very limited amount opening or trismus.
And when they have a diminished quality of life, because you can imagine never being able to eat a
hamburger, or open your mouth widely to eat salad, or living your life having blunderized food, you
know, like a newborn, can be devastating. You know, eating is a social activity, and you are going out to
eat with friends, and you are ordering a smoothie every day. Not healthy. Patients who have other oral
surgery procedures who are not able to get better, may be good candidates for joint replacement, and
patients who have arthritis, specifically ankylosis, or others problem with the jaw, will come to the oral
surgeon to have the joints replaced. Its not usually the first line of treatment because we try other
things first, its a big operation, but a lot of patients require it.
Slide 28 Prosthetic
So these are some of the options that we have. Sometimes we can use a prosthetic joint, and part of the
prosthesis includes a fossa component. So these are made on the 3D model that I showed you, we do a
3D CT, we make a model, you can literally hold it in your hand, and the laboratory can fabricate, these
are chromium cobalt alloy components. This is one part that will go on the backside of the jaw, this is to
replicate the fossa. And this is a little spacer in the middle, because it will line with soft tissue where the
disc should be.
Slide 29 Stock
Sometimes we have them premade. So these are stock, meaning that they come out of a rawer, we
have small, medium, and large because everyone is a little different. Some patients require custom. So
tehre are some kind of alloplastic materials that we can use in order to reconstruct the joint.
Slide 30 Autogenous Grafts
This patient had her rib bused. So a costochondral graft is taking a piece of someones rib and putting t
into the TMJ is another option for reconstruction. This patient was young, she was still developing.
Theres nothing like taking your own source because theres no source of rejection. The rib is a
costochondral graft, which means that the rib has cartilage on it. So youre transferring one piece of
cartilage to another area that needs the cartilage. And Ill show you pictures of her. And this is a
different patient but this patient had their rib inserted. The rib actually regenerates, you know you have
12 of them on both sides, you can live without two, we take one for each side, if its bilateral. But the rib
is an option. Some other times we take the big toe, take the nail off, of course. But the shape of the big
toe sorts of looks like the condylar head. But you cant walk, you cant wear flip flops that was a joke
but you can walk. You guys are very serious, thats ok. Ill laugh ot myself. The big toe is an option,
because again, it has the cartilaginous shape.
Slide 31 Case
But this patient, because shes a young adult and because shes developing, we wanted to save the
prosthetic options for the future in case these didnt work. And she was willing to undergo another
procedure. So as oral surgeons we are also trained to take and graft from other sites of the body.
Sometimes we do bone grafts, we take bone from the skull. Sometimes we take bone form outside the
jaw. Sometimes we take grafts from the leg or the arm, but for this, especially for TMJ reconstruction,
the TMJ is a wonderful alternative. So we literally drill on her so we can find where the ribs are. We
often take the 5
th
and 6
th
rib on the side opposite from where the heart is, because if she has pain after
surgery, we dont want to confuse it with any chest pain related to her heart. And we do an incision right
underneath the breast area. We go through the skin, through the fat down to bone, and this is what the
ribs actually look like. We specifically left the cartilaginous cap on because were gonna transplant them
into the head and neck.
Slide 32 fixation
So once weve removed the ankylotic mass we make another incision underneath her jaw. This is the
temporalis muscle thats gonna line the bone to recereate the joint space where the disc wouldve been.
When we do ankylotic surgery we dont replace the disc, so you can fucntino without a disc, but its
much more comfortable to ave uscle between the bones, the skull base, and the condyle or the rib, so
that they dont rub. And then we can put the bones back where they need to be.
Slide 33 Picture
So as shes asleep we can open her mouth and stretch her mouth. And look, she can open more than
45mm, and thats great! So we know that we did a good job. And because were able to reestablish her
maximal incisal opening, the goals of the procedure have been achieved. She still has a long road ahead
of her, she has to do physical therapy. This is an example of that, using tongue depressors. Each tongue
depressor is about 2mm thick. So if you want to open 40 you have to use about 20 stick. So every day we
ask the patient to add another stick and add another stick, and eventually, sort of like crosstraining
eventually shell get there.
Slide 34 Post Panorex
This is an x-ray after surgery was done. These are little screws that are used to hold the ribs in place.
One rib on the left, one rib on the right, and she was treated. So although this was a very severe case of
ankylosis I think its important to know that when patients have fractures of the TMJ we take ti very
seriously. So next Im gonna show you another case of some mandibular fractures.
Slide 35 Case 2
49 year old make patient comes after an assault, so he was attacked. He has mandibular pain, trismus,
cant open very widely, and a malocclusion, meaning that when he puts his teeth together, his teeth feel
off. If you put your teeth together, may not be comfortable, because you dont often sit with your teeth
crunched. We tend to just hang out. But if you put your teeth together, its sort of reproducible, you can
do the same bite every time.
Slide 36 Panorex
This patient has a fracture, so we took a panorex, and it may be hard to see, and Ill show you on the cat
scan, this is the left side and the bone here is displaced. Can you see how theres a step here? its not
nice and smooth, but this whole segment is displaced.
Slide 37 CT
So we took a CT scan, he has two fractures. One is through the jaw, this is called the mandibular body
where the teeth are,. This is his airway, this is his jaw up in the air. This is called an axial view, and these
are called coronal views because these are from the top. So this is the base of skull and this is the airway
again. But you can see how the bones are not lining up so theres obviously a fracture there.
Slide 38 Trauma
So when someone comes with mandibular trauma, theres a fracture here, different patient, some of
the signs and symptoms would be what? Obviously pain, what else? Swelling. Trismus. Probably nerve
dysfunction because the alveolar nerve may have been severed so they may have numbness on the jaw
or the skin. And some of the treatment option would be to use bone healing.
Slide 39 Treatment options
So this is another case thats treated by an oral surgeon. When patients have fractures theyre referred
to the hospital. We do a lot of these procedures in the operating room with anesthesia, mostly for
patient comfort. But one example of how we fix fractures is we use rigid fixation. And what that means
is we do an operation where we cut through the gum, find the bone, line them up and put on some sort
of bone plate with screws. Sort of how we fixated the ribs in that other patient I showed you. Another
option for treating some patients is we really wire their teeth together like this for about 4-6 weeks. So
you imagine 406 weeks of having your teeth locked is challenging. You can only brush the outside, you
can drink through a straw. You can throw up because if you can drink and swallow through a straw you
can definitely throw up through closed teeth, but definitely not comfortable. Sometimes we have to
wire patients together because their fractures are just so bad that if we try and put them back together
the blood supply will be distorted. Sometimes when patients have fractures of the TMJ we do wire them
together but for a shorter period of time, about 2 weeks, because if you wire someone together longer,
the risk of ankylosis increases. So thats why fracture repair can be challenging.
Slide 40 ORIF
So this shows you on a microscopic level. When we do primary bone healing which means bone plates
and screws. We do an operation, open up the gum, find the bone, we line them together and we put a
plate across. The osteoblasts can literally jump from side to side. Sort of like if you had pins or plates for
some sort of orthopedic surgery.
Slide 41 Secondary bone healing
Secondary bone healing is when you wire them shut its sort of like putting a cast on the jaw. Just like for
a cast the doctor doesnt make sure the bones are perfectly lined up. He or she puts them where they
best fit and that keeps them immobilized. Same thing with this. So although it heals with a callous, the
bones eventually can be remodeled, and function can be restored.
Slide 42 - Secondary bone healing
These are some pictures of wiring patients shut. So this is a gentleman who was wired shut. He actually
was edentulous, no teeth. So you can imagine if you want to wire someone shut who has no teeth,
youd have to either put wires on the dentures and fix the dentures to the jawbone, either we use a
palatal screw or we wire it to the lower jaw. Or sometimes we have to make splints, these are likes
acrylic models of the jaw and we can wire those together. This is typically what it looks like, we put
braces on, because most patients dont come in having had orthodontics, most patients have fractures
and they are not in braces, and then we literally wire the teeth together.
Slide 43 biomechanics
When we do fracture repair, different aspects of the jaw show different areas off flexion, tension,
extension. And you can imagine, when you put your teeth together, and bite down hard, different areas
of the jaw take different amounts of forces. So it's very challenging for us to figure out the best way to
stabilize the jaw. And often times we use small plates and screws, but sometimes we will use the wiring
shut together.
SLide 44 - Case
So I'll show you what we did for this patient, so we took him to the operating room, we put him to sleep,
we drew on his face, because I wanted to find where the fracture was. This line shows you where the
fracture is, so you want to go below it. So you want to make an incision in his neck, go through the skin,
go through the muscle, go through the vessel, we find the bones, literally put them together, his teeth
are wired shut just to help us in the beginning.
Slide 45
And then we put on bone plates, and screws. These are made of titanium, they stay on permanently,
because the goal is to keep the bones together. So the bones can heal, and bone, literally new bone, can
grow over that. So they're very very stable. They don't interfere with MRI, they don't react with metal
detectors, it's not like at the airports, he's going to go off, he knows that they're there, And so do we.
Slide 46 - Post Panorex
And this is how we treated him, so we wired his teeth together, because he had a fracture of the TMJ.
And then you can see we put on a plate up here, four screws, and a plate up here. So here is one
fracture, Through the bone, see the black line, And here is a another fracture through the TMJ. And now
the bones are lined up. And over time, we will get him some functioning, opening and closing, practicing
with the tongue depressors, so that he doesn't develop Trismus.
Slide 47 Case 3
Heres another patient. 27 year old female patient came in after she fell from standing. She didnt eat
breakfast, it was super hot outside, she was waiting for the subway, and boom, collapsed on the
pavement. Problem is, she landed on her chin. And when you have a traumatic event and you have a lot
of force on your chin, you can imagine it puts a lot of pressure on your condyles. So a blow to the chin
often makes us worry that theres some sort of fracture of her jaw elsewhere.
Slide 48 Extraoral
So you take a look at her, she has some deviation, her jaw goes to one side. This is where her skin was
roughened up after the fracture.
Slide 49 Panorex
We take a panorex and look, this is the right side, its always seen as though youre looking at the
patient. So this is the right side of her, this is the left, and I hope you can see how the right side is in the
TM joint, its in the articular fossa. The left side, whoa, totally cracked and fallen over. And the reason
why the condyle falls over is from muscle pull. So the muscles are unopposed, they pull and they drage
the condyle.
Slide 50 CT scan
This is what her CT scan looked like. It just went click, and the top part of the condyle literally fell off the
neck of the jaw. Still attached but its not in the right place.
Slide 51 Options
So we were consulted in the hospital, they asked us to treat her, and one way to treat these types of
patients is like the previous patient, to put on bone plates and screws, thats primary bone healing. But
another way to treat these patients is to wire them shut for about 2 weeks, as long as you can line up
their teeth, the bones tend to heal, even if its not perfect in the right place. And we risk not putting her
into an ankylotic condition. Only 2 weeks. And then we can put on elastics and she can function up and
down, but at least she can get the jaw moving. A lot of the problems with the very first case I showed
you, with the ankylotic case is because she didnt have proper treatment. So because it was left to heal
on its own there was no physical therapy, there was no motion, the bone was stagnant, a lot of that
blood turned into bone, and thats why her bone was frozen.
Slide 52 Open vs Closed
So a lot of times we do open reduction, meaning bone plates and screws, especially if the fractures are
unstable. Al ot of fractures, they dont stay together, we tend to use that. But sometimes patients can
be wired shut. Can you think of any medical conditions that maybe you wouldnt want to wire a patient
shut like that. Sure, so very severe asthma. So one would have a very difficult time getting the medicines
in unless he crushed them. what else? There are medical problems youre gonna go around like this for
at least 2 weeks. So Bulemia, absolutely, Id be very worried about chronic malnutrition, that person
couldnt get a healthy normal diet unless it was protein shakes. and absolutely, if the person was
vomiting, That would be a problem. A seizure disorder, could be very dangerous if someone has
uncontrolled epilepsy. Someone who needs medications that can't be crushed, a lot of psychiatric
medications can't be crushed, they have to be swallowed whole, and it can be hard to fit around the
site, especially if you can't open your teeth. So sometimes we decide to wire patients shut. So it's a very
complicated decision to be made, can we do it or can we not? What's interesting to me is that when we
compare the patients that we did the bone plate and screws to the patient that we wired shut, six
months out, patients who had surgery can't open that much, why do you think that would be? Surgery I
mean making a cut, opening it up, putting on the bone plate and screws, why do you think that patients
who had surgery would have less opening? Okay, She said trauma already from the surgery, so what do
you think the surgery would cause? Scar tissue. And it can make it difficult to open and close. So it's
interesting. So we have a discussion with the patients. Some patients will say I work in marketing, I have
to be on the telephone in two days, I cannot be like this. I once took care of a News reporter for Channel
one, I don't know who watches Channel one, I think it's New York one, he had to be functioning, and
couldn't do this, so it's a lifestyle choice that can sometimes make a decision. But often times patients
don't do as well with a bone plates and screws. So we have a complicated decision.
Slide 53 - Case
This patient we decided to wire her teeth together for about two weeks, and over time - even though
this may not be perfect lined up - It does heal in the right place. So once the teeth are lined up, the
muscle go back to their normal function, The jaw is allowed time to rest, sort of like putting on a cast,
and it's actually heals. Fascinating, to me. No laughing. We are doing great.
Slide 54 - Case 4
Case number four, 26-year-old man is seen after suffering a fall after heavily intoxicated. He is now
sober, and complaints of double vision, so he looks at you, and sees two. For he looks at his hands and
it's very very blurry. And his cheek is numb. So we've been talking about facial fractures, broken bones,
what do you think? Why would your cheeks be numb? What bones could be fractured? Sure, so some
sort of orbital components, maybe the bones around the eye, he also has ankylosis, or should I say
trismus. Maybe from the zygomatic arch. And his cheek was probably numb from involvement of what
nerve? What nerve is responsible for sensation to the cheek? V2, or the infraorbital branch. So we did
an exam on him, we took an x-ray. And a lot of looking at facial fractures is comparing both sides,
looking at which side is different than the other.
Slide 55 - CT
So this is looking at someone face on, This is called a coronal view. This is the eye socket, this is actually
the globe. These are the muscle, they are all gray. Because CAT scan primarily show hard tissues. Air is
black, and bone is white. And everything else is the grey in the middle. These are all the sinuses around
the nose, these are his maxillary teeth, he fractured the floor of the orbit. So the floor of the orbit on the
right side allowed to sinuses to be filled with blood and mucus and air. And here it shows you another
slice. This is looking down at the patient. This is his eyes, this is his nose, and there is a fracture of the
zygomatic arch.
Slide 56 - Zygo Complex
so this patient broke a bone that involves the bottom half of the eye, the side of the cheek. In the
beginning I showed you that you can have extracapsular trismus, or extracapsular ankylosis. If a portion
of the zygomatic arch impinges on the condyle and the coronoid. He had pain, he had a lot of swelling,
what do you think ecchymosis means? Have you seen that before? Ecchymosis means a lot of bruising.
Black and blue from blood. Malar flattening means his cheeks look very flat. A palpable step, When you
touch the bottom of the eye it's not very smooth, It feels like a puzzle that's not put together right, it
feels like a step. he had trismus, because the zygomatic arch was impinging on the coronoid and the
condyle. Subcutaneous emphysema, that means air underneath the skin. So it's like popcorn. You could
touch it, and it's like those things that you used to pack packages. You people love to pop that, I don't
know why. You know that plastic with like all the bubbles, it feels like that. And his whole cheek was
numb. And the cheek was numb because the infraorbital nerve that comes out of the infraorbital
foramen was involved.
Slide 57 - Anatomy
So as oral surgeons, We are often called upon to treat these kind of fractures. They are called ZMC, or
zygomaticomaxillary complex fractures. They are called tripod, which is really not accurate. Because it
actually four sutures, sort of like a quatra-pod. But there are different suture lines in the head and neck
that fuse as we get older, And they're more resistant to injury. So if you take a blow to the face, the
sutures are weaker inherently, and are more likely to crack..
Slide 58 - Open Reduction
So the way we treated him was through primary bone reduction, or primary bone healing. We took into
the operating room and we put on bone plates and screws.
Slide 59 - Case
He was asleep, he had a breathing tube in his mouth, because we were working on the eye near the
nose. We made an incision right underneath the eye, and lifted up all the skin, And this is to show you
his eyeball is protected underneath the retractor. But here is the bone of the infraorbital area, The
orbital rim, the infraorbital floor. And there is the line. And that the crack. We also put on a plate in his
eyebrow, because the fractured that suture as well.
Slide 60 - Case
And then the fracture of the maxillary sinus. So we made a cut inside of his mouth and we were able to
put it in bone plates and screws. And we restored normal mandibular functioning.
Slide 61 - 4 weeks
So about four weeks out, he's still a little puffy. His eye looks a little swollen, but his cheek doesn't look
so bad. So that's an example of a patient who had trismus from a traumatic reason. But it wasn't related
to the condyle, it was related to the zygomatic arch that was compressing it.
Slide 62 - Case 5
Alright, two more cases and we're done. 28-year-old male patient presents with a history of recurrent
odontgenic keratocysts. So this is an example of pathology. The patient had half the keratocysts treated
three years ago. Keratocysts, have you heard about this before? Common pathological findings, it's
benign, but it's aggressive, meaning it can grow, it can divide, It can become possible, it can recur. So
they often require treatment. And one way that we treat them is we scraped their mouth, that's what
keratoge means. We simply scoop them out, and let the bone heal. So one of them was near his wisdom
tooth, so when we saw him to take out his wisdom tooth, we saw it near his third molar, we scooped it
out. But lots of interesting for you to note is a patient who has multiple, especially if a patient who is
young, they have a syndrome.
Slide 63 - Gorlin
And the syndrome is called Gorlin syndrome. And the reason why this is important, but because basal
cell carcinoma is a common feature. Basal cell carcinoma is malignant, so patients must be evaluated by
a dermatologist, a general physician, a general surgeon, an orthopedic surgeon, An oral surgeon, several
specialists. So anyone who have multiple odontogenic keratocysts, or OKCs as they're called, should also
be worked up, and now we know the genetics for this disease. It's also hereditary. But this is an example
of a Panorex of a patient who had syndrome. and OKCs looks like multiple radiolucencies. So it's sort of
look like multiple soap bubbles throughout the jaw. The person also had other findings to, but you can
imagine multiple openings in the jaw makes the jaw weaker. And unfortunately, the patient trips or falls,
or eats the wrong way, the jaw is very susceptible to fracture.
Slide 64 - Case
So this is what this patient looked like. And you can see, this is not something on the x-ray, these are
actual odontogenic keratocysts. These are really big. But I think this case is relevant to our topic,
because it approaches the coronoid, and it takes up a big portion of the condylar aspect of the jaw. So
we have already scooped him out once, and this is a CT scan, and again this is the lower jaw, this is the
area where the lesion was, and the big circle shows you the OKCs. And this person needed TMJ
reconstruction, because we got to the point where we are scooping and scooping and scooping, And we
cannot do that multiple times, because he will develop ankylosis from surgical scar. So we had to replace
the joint.
Slide 65 - Preauricular swelling
Whenever you see someone who has swelling on this side of the face, it could be a TMJ problem. Often
times it can be related to infections, mumps is pretty unusual, especially with vaccinations, but
theoretically it can be possible. Parotitis means inflammation of the parotid gland. Could be neoplastic,
could be a tumor inside a salivary gland, and neoplasia is always on the differential diagnosis of an older
patient. Or it could be a foreign body like a salivary stone.
Slide 66 - Diagnostic
It's important that you examine the patient extraorally, outside the mouth, intraorally, doing an exam, x-
rays, I've showed you examples of Panorex X-rays. As surgeons we often like to see things in 3-D, so I
often will get a CT scan, and it's important to refer to the oral surgeon early. Because a lot of these
patients require treatment, and the treatment is often surgical. Typically, we will take a biopsy, which
means we will take a small sample, we will send it to the laboratory to look at it underthe microscope.
And then treatment options. Some of the treatment options I've shown you, we can do a biopsy, We can
remove a lesion, we can treat the joint, we can do reconstruction.
Slide 66 - Case
So this is the patient who had multiple odontogenic keratocysts. Took the patient to the operating
room, we made an incision, we cut out the entire piece of mandible that was involved. This is a wire, just
to show you, that we didn't make a hole, the OKCs, the odontogenic keratocysts literally perforated
through the mandible, they were so big, and all that pressure created a hole in one side.
Slide 67 - Picture
And then we reconstructed the person with the plate, and then we went back in to do custom TMJ
reconstruction.
Slide 68 - Closing
So those are the casesI have, you can always e-mail me if you have questions. It's 9:43, so we have the
room for another seven minutes. I'll be happy to take questions if you want. I don't expect you on your
exam to know the technical aspects of what we talked about. But I would have a general sense of what
its primary bone healing?, what is secondary bone healing? what is ankylosis?, how can it happen? and
what are the types of treatment modalities that we have to fix it? Wasn't this interesting, or totally
gross? Interesting? Okay good. Thank you. Good luck studying. If you have any questions, I'll be happy to
take them, or if you want to come up here if you totally can.