Introductory Chapter: Evolution of the Temporomandibular Joint Surgery

1. Introduction

1.1 History of temporomandibular joint (TMJ) disease and surgery

The temporomandibular joint (TMJ) disease and surgery was known since ancient years. The temporomandibular joint is unique in its development, anatomy, and function and the disease that affect the TMJ rather different from other joints. It consists of two joint cavities one superior and the other inferior in between the articular disc and is covered by synovial fluid that comes from synovial pharynges inside the capsule for lubrication of the TMJ and protein nourishment of the cartilaginous parts of the joint [1, 2].

During the second world war, two great people, Sir Harold Gillies and Sir Kelsy Fry, put the foundation of maxillofacial surgery, and after the war, they did establish the Plastic &Maxillofacial units distributed in all the country where sited in the presence of industrial cities and near the high roads through the NHS, great understanding the disease of the TMJ occurred [2].

It was a challenge for all craniomaxillofacial surgery and research to understand the disease that affects the TMJ. In the fifties, sixties, and seventies, it was great difficulty to understand the problems and disease of the TMJ.

Ankylosis of the TMJ unpleasant disease was not common in western countries but exists in underdeveloped countries because of lack of education and poverties. The cause of this unpleasant disease is more probably due to trauma during childhood affecting the joint and might suppurative infection comes from otitis media, we studied this disease, that not only the patient cannot chew food with facial deformities and disturbance of anatomy of the upper respiratory tract and complaining from sleep apnoea [3].

In the mid seventy of last century, we did find the solution for management of people suffering from this disease by advocating two-part chrome cobalt prosthesis to restore the function of the TMJ in adults. We faced another problem, the disease once affect children not only damage the function but also the growth of the mandible and midface [3, 4, 5, 6].

In the mid seventy, David Poswillo 1974 advocated the Costo-Chondral graft and its application for reconstruction of the damaged TMJ for restoration of growth of the condyle. It was a revolution in surgery of the TMJ at that time and he supported his work by experimental studies on Monkeys, this graft was Widley used for reconstruction of TMJ in both children and adults for 3 decades [7].

In the mid eighty of last century 1986, we did advocate the Chondro-Osseous graft for reconstruction of the TMJ for restoring growth of the condyle as growth centre in children, this graft proved to be much superior to Costo-Chondral graft, because the cartilage cap in Chondro-Osseous graft is more stable and the other might dislodge during operation and also might pneumonia of the thorax have developed and unpredictable growth pattern occurred and reported [8].

We carried out an experimental study on rabbits to understand the cytology of the Chondro-Osseus graft, the articular part of the graft consisted from dense fibrocartilage layer as the first layer, the second layer consisting of several layers of round mesenchymal stem cells, the third layer consists from several immature chondrocyte and passing through series of operations to mature the chondrocyte and the fourth layer consist from bone marrow and osteoblast cells [8].

This graft proved to be an ideal graft substitute to the condyle for restoring growth, remodeling and repair of the TMJ. The graft was applied in cases of ankylosed joint in children, in hypoplasia of the condyle, and in first arch syndrome.

Fred Henny in the mid sixty suggested the use of high shave operation of the condyle to decrease the growth of the condyle in hyperplasia of the condyle during puberty, and he did use this operation for relief of pain in osteoarthritic changes of the articular layer in old people, he supported his technique by application of few drops of hydrocortisone. This technique was very popular during the sixty and seventy last century [1].

Further research done by experiment on rabbits of bone grafting has been done recently to understand the cellular changes associated with bone grafting, we did observe that the graft was invaded by capillaries after 24 hours coming from periosteum and muscles covering and mesenchymal stem cells coming from bone marrow of stump and platelets growth factor (PGF) coming from platelets, the success of bone grafting is based on decortication of both stump of bone and graft with rigid fixation [2].

2. Recent improvements in diagnosis and diagnostic tools

The improvement of diagnostic tools recently of the TMJ were greatly improved by using an electronic stethoscope for detection of disc movement and condyle relation in cases of hyper mobility of TMJ. Also, biomechanics of the TMJ studied the movements of the condyle and anatomy of muscles functions and the results were optimistic. The orthodontic treatment is required for correction of occlusion because mal occlusion creates a disturbance in relation of the disc to the condyle. Pain usually associated with TMJ disease should be eliminated from trigeminal neuralgia, migraine, muscle spasm, and tooth pain [1].

More work and research have been carried out recently by application of physiotherapy for managements of temporomandibular joint disease for the relief of pain and spasm of joint muscles.

Arthrography is an excellent diagnostic aid for studying the disease of disc displacement and deformity of the disc including disc perforation. Another diagnostic tool is the MRI for studying the soft tissue component of the TMJ including disc pathology and even perforation of the disc which might require meniscoplasty by using temporal fascia for repair of the disc or we might use sialastic sheet of 1 mm to replace the disc [1].

Recurrent dislocation and subluxation are unpleasant diseases; the patient became nervous, upset, and depressed. It affects both young and old people; the situation is that when the patient once dislocated his condyle of the joint and became unable to close his moth. Acute dislocation can be managed in the clinic by giving local anaesthesia to the joint, and the mandible was reduced by our new technique by standing behind the patient, and the operator should ask the patient to be relaxed. The surgeon hold the body of the mandible and using the angle as pivot by unilateral rotation of the condyle; the dislocated condyle jumped to glenoid fossa and other side reduced immediately. This technique been used instead by Hypo crate, 2000 BC technique by pushing the mandible downward and backward, which is no more accepted and very destructive [9].

Chronic recurrent dislocation or subluxation occurred due to lax capsule and resorption of articular eminence more common in Yamen, Somalia, Sudan, and Saudia Arabia due to habitual chewing of Qat for several hours per day; The Qat with amphetamine-like action passing through two stages. In the first, he became alert and in the second stage became fully relaxed and sleepy. Qat is a very destructive drug-like action to TMJ by converting the passive movement to active movements with severe damage to TMJ [1, 9].

The most recent technique for reconstruction of the TMJ for the above disease of chronic recurrent sub-luxation using temporal fascial of finger like with inferiorly based used for reconstruction of the lateral wall and anterior wall of laxed capsule for reinforcement and using a piece of bone graft impacted in ostectomy site in front of atrophied eminence as an obstacle for further movement of the condyle forward [9].