FINDINGS:
This is a ***-year-old *** who underwent conservative therapy for temporomandibular joint dysfunction. Cone bean CT demonstrated no irregularities with the left joint complex. Evidence of anterior displaced disks without reduction were noted bilaterally on MRI. The patient clinically had significant decreased range of motion and chronic recurrent pain, not resolve with conservative means.
The patient underwent an arthroscopy bilaterally and she failed to control her pain no improve her range of motion. The case was discussed at length. Risks, benefits, and alternative therapies reviewed. Clinical indication for a modified condylotomy procedure was reviewed in detail
with the patient. The patient is being taken to the operating room with the understanding that the post-operatively she will requires six weeks of intermaxillary fixation on a liquid diet, and still has the risk of recurrent pain and discomfort with the temporomandibular joints.
PROCEDURE:
The patient was taken to the OR, placed in the OR table in supine position. The patient was induced under general anesthesia, maintained via nasotracheal intubation. The patient was prepped and draped in the standard fashion for an intraoral surgical procedure.
The oropharynx was thoroughly suctioned. A posterior throat pack was placed. Approximately 10 mL of 1% Xylocaine with epinephrine was infiltrated into the proposed incision sites of the mandible bilaterally. Erich arch bars were circumdentally ligated to the existing dentition between first molar to first molar of the maxillary and mandibular arch forms. With the arch bars in place, attention was directed to the mandibular osteotomies.
With the use of a needle-tip Bovie, a standard degloving incision was made along the ascending ramus of the right mandible, extended along the external oblique ridge, and into the mucobuccal fold adjacent to the second molar. Soft tissue dissection proceeded in a subperiosteal plane,
degloving the entire posterior body and ramus portion of the mandible. Anatomical landmarks to include the sigmoid notch, neck of the condyle, posterior border of the mandible, angle of the mandible, and antilingula were identified. With appropriate retractos was placed, under adequate Visualization and irrigation the right ramal osteotomy was initiated from the sigmoid notch to the angle of the mandible using an oscillating saw. Once completed, the segments were displaced. Disinsertion of a portion of the medial pterygoid was completed with splaying of the bony segments. Attention was directed to the contralateral side where a similar incision and dissection were completed. Surgical exposure of the left ramus was gained. All anatomic landmarks were identified. A similar osteotomy was completed without complication and disinsertion of the medial pterygoid muscle proceeded without complication.
The oropharynx was thoroughly suctioned. The posterior throat pack was removed. The patient was placed into intermaxillary fixation with the use of #26-gauge wire. Bony position of both condylar segments were noted in good bone-to-bone apposition. The surgical sites were thoroughly irrigated with normal saline and thoroughly suctioned. Closure followed with the use of 3-0 Vicryl and 3-0 chromic suture.
This concluded the surgical portion of the case. The patient was extubated in the operating room and taken to recovery in stable condition.
