Mitek Anchor Surgery

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3. Mitek Anchor Surgery
Many patients who present for orthodontic corrections have some form of
temporomandibular joint dysfunction (TMJD). These problems can extend from
rather simple to extremely complex. The most difficult category includes those
patients with internal joint derangement. Patients with dislocated non-recapturable
temporomandibular joint (TMJ) are provided a new method of treatment. Mitek
Anchor Surgery: Orthodontic patients are evaluated to determine whether they
posses signs and symptoms of TMJD, or do they have normal joints. A joint is
normal when the following characteristics exist: Painless, noiseless, full range of
motion, and without deviation or deflection. A normal patient is generally free of
headaches, neckaches, earaches, facial or joint pain.

The condyle should contact the central avascular portion of the disc which should
function against the anterior slope of the eminence. There should be a consistent
contact of these structures in all movements without any displacement or
dislocation of the disk. The joint structure should be supported by normal muscle
function with a Class I mutually protected occlusion.

The force applied by the condyle

should resemble the black arrow in the diagram (left). This would maintain the disc
position between the condyle and fossa. The condyle should not exert a straight
upward vertical force against the disc as this would cause a distortion of the back
(posterior laminar zone) of the disc. The enlarged posterior lamina helps maintain
the disc position between the ball(condyle) and the socket or front wall (eminence).
Posterior forces by the condyle would exert pressure against the posterior
connective tissue, arteries, venules and nerves. There is no joint within the body
where the forces are directed in this manner, leading Ide and Nakazawa to
consider the up and back (posterior/superior) vector as a pathologic force.

Normal joints exist when the

condyle exerts a force against the avascular central region of the disc (A). The
condylar force exerted backwards (posterior and superior) distorts the back
(posterior aspect) of the disc, decreasing the mechanical lock mechanics of the
enlarged structures. Further compression continues the distortion of these back
(posterior) structures, facilitates a thinning of the attachment, until the mechanical
locking advantage is lost. When this occurs, the disc can become displaced. The
posterior ligaments are stretched and the disc is pushed forward by the ball
(condyle) until it becomes displaced or dislocated (left).

Normal joints should be painless,

noiseless, with a full range of motion without deviation or deflection. In the
beginning a patient presenting with this condition may not exhibit all the classic
symptoms associated with a dislocated joint. Dislocated joints are not always
painful, they do not always produce noise, but there would probably be a
decreased range of motion and a probable deflection upon opening to the side of
the dislocation. Joint noise should be a red flag to investigate the conditions of the
joint to determine the cause of the noise.
 When it is determined that a
patient may have a displaced or dislocated joint, further diagnosis is warranted.
Often this involves extensive radiographic evaluations, or other tests. An orthotic is
a clinical means to evaluate the conditions within a joint. The response received
provides information regarding the health, recovery potentials, and magnitude of
dysfunction which may exist.

The usage of intraoral orthotics is

essential to adequately diagnose joint conditions. There are many derivations of
the basic splint design. It is essential to know what each appliance can do and be
able to use the proper orthotic at the proper time. Usage of the wrong appliance
provides inadequate information leading to an inaccurate diagnosis, or it may
further the degeneration of the structures.When a patient does not respond to
conventional diagnostic orthotics, further evaluations are necessary to determine
the conditions within the joint. Often a magnetic resonance image (MRI) is used to
examine the joint structures to determine the position and possible integrity of the
disc. The following MRI demonstrates dislocated joint which does not reduce upon
opening. The disc tissue (yellow arrow) is positioned in front of the ball of the joint,
but retains a decent shape. This type of patient may be a candidate for Mitek
anchor therapy.
 The arrow points to the dislocated
disc with the mouth closed. The condyle is positioned posterior/superior to the disc.

Upon opening, the disc remains in

front of the condyle which is restricted in joint extension. Conservative therapy is
unable to reposition the condyle to allow adequate room for the disc to “slip” back
into the proper position (recapture). A decision must be rendered concerning the
future health of the joint. Should the disc be allowed to remain dislocated, or should
the disc be surgically repositioned?One method to evaluate the health of the joint
involves the use of a quantitative radionuclide bone scan. Reference articles are
provided if additional information is required concerning these tests. Assuming the
bone scan is positive (indicating inflammation and an elevated osteogenic activity),
it is not prudent to allow the positive on-going degenerative conditions to persist.
Therefore, further intervention is warranted and the Mitek anchor treatment may be
considered.
Method:
A Mitek anchor is a titanium condylar implant which is surgically placed in the
posterior (back) aspect of the ball or condyle. Access to this region is made
through a small incision in the ear canal (the external auditory meatus). A small
incision is made in the front wall of the ear canal (external auditory meatus)
exposing the back (posterior) aspect of the temporomandibular joint structures.
 The incision avoids the structures
of the facial nerve and many of the larger arterioles and venules found on the side
of the face. Numbness (parasthesia) is extremely rare when avoiding the side of
the face, but can occur. The incision is continued until the posterior aspect of the
condyle is exposed.The Mitek anchor is composed of a titanium body with Nitinol
wings with a small opening in the posterior aspect of the anchor body through
which single or double thread O-Ethibond sutures can be passed.

The disc tissue is found and

prepared for placement with a proper relationship to the condyle. A surgical bur
makes a precise opening in the back of the ball so the anchor can be placed. Once
the anchor is driven to place, tension will be applied to the sutures to engage the
anchor wings.
 The Mitek Anchor with the sutures is secured in a
holding/delivery device which is used to carry the anchor attachment to the
condyle.

The point of the anchor is inserted

into the opening which was drilled into the posterior aspect of the condyle. The
mandible is supported and the anchor is tapped home.

Once the anchor is securely

tapped to place, tension is applied to engage the wings. This posterior tension
serves to engage the anchors as they become anchored into the bone. The anchor
is then properly secured so the non-resorbable threads can be used to help
position the disc into the desired position.
 Here we can observe tension
applied to the non-resorbable threads to “seat” the anchor in the bone. Now the
disc can be position and secured in place with the non-resorbable sutures.

This diagram illustrates the Mitek Anchor in place with the Nitinol
wings imbedded into the condylar bone. The sutures serve to maintain the disc in
the proper position. If the ligaments can be salvaged, they are allowed to remain in
place and recover some function over time.

Viewed from the posterior, this

diagram demonstrates suturing the disc is maintained by the Mitek Anchor. This
attachment helps maintain the disc in the desired position. The remnants of the
posterior tissue can be reattached. The wound is then closed with sutures.
 There is one additional advantage
to this surgical technique. The beginning etiology of dysfunction was a posterior
movement of the condyle which compressed the disc tissue and began to alter the
posterior lamina and posterior connective tissue. The procedure into the posterior
aspect of the joint space causes a slight swelling which serves to force the condyle
forward against the disc and front wall of the socket (eminence).It is necessary to
maintain the forward posture of the mandible to ensure the condyle does not return
to a posterior pathologic position. This may involve post-surgical orthotics and/or
other corrections to ensure the proper mandibular – maxillary relationship is
maintained.
Results:
This technique can be used to reposition a disc that has not been too destroyed
and retains its structural integrity into a more physiologic relationship. The Mitek
Anchor provides a method for securing the disc to the condyle, but the health of the
disc, the loss of lateral or medial ligament attachment and the loss of the posterior
connective tissue vary from patient to patient.This procedure corrects the effects of
the inter-joint injury. The post-surgical swelling serves to reposition the mandible
slightly anterior, but this may not be a permanent alteration when the swelling
subsides. Additional treatments may be necessary to help maintain a physiologic
position of the mandible.

Discussion:
A normal position of the condyle exerts an anterior-superior force against the
avascular central portion of the disc. This force coincides with the physiological
force vectors applied by the muscles of mastication. A condyle positioned superior
or posterior superior exerts forces on the disc structures which cannot be
physiologic. The disc structures compensate and undergo compensations to the
condylar pressure. The disc may become displaced or dislocated as the condyle
moves more posterior.
A dislocated non-recapturable disc may need to be repositioned to allow a more
normal function of the mandible. The Mitek Anchor offers a moderately invasive
surgical procedure to reattach a dislocated disc. The minimal swelling which occurs
immediately after surgery helps maintain an anterior force on the condyle – disc
assembly.

The surgery treats the effects of the injury. Post surgical corrections may be
necessary to treat the cause of the dysfunction to maintain the proper forces upon
the joint structures. This may involve post-surgical orthotics, prosthesis to maintain
a functional relationship, or TMJ-orthodontics which approximates the dentition to
maintain the functional mandibular – maxilla association.