Arthroscopy of The Temporomandibular Joint

ARTHROSCOPY OF THE
TEMPOROMANDIBULAR JOINT
Wolfram M. H. Kaduk
ARTHROSCOPY OF THE
TEMPOROMANDIBULAR JOINT
Prof. Wolfram M. H. KADUK, MD, DDS
Consultant Oral, Maxillofacial and Plastic Surgery,
Orthodontist and Oral Surgeon
Hospital and Outpatient Center for Oral
and Maxillofacial Surgery Plastic Surgery
Ernst-Moritz-Arndt University, Greifswald, Germany
Drawings:
The schematic anatomical drawings were made
by Mrs. Katja Dalkowski, M.D.,
Grasweg 42, D-91054 Buckenhof, Germany
E-mail: [email protected]
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Arthroscopy of the Temporomandibular Joint

Prof. Wolfram M. H. Kaduk, MD, DDS
Consultant Oral, Maxillofacial and Plastic Surgery,
Orthodontist and Oral Surgeon
Hospital and Outpatient Center for Oral and
Maxillofacial Surgery Plastic Surgery
Ernst-Moritz-Arndt University, Greifswald, Germany
Correspondence address of the author:
Prof. Dr. med. Dr. med. dent. Wolfram M. H. Kaduk
Facharzt fr Mund-Kiefer-Gesichtschirurgie /
Plastische Operationen, Kieferorthopde, Oralchirurg
Klinik und Poliklinik fr Mund-Kiefer-Gesichtschirurgie /
Plastische Operationen
Universittsklinikum der Ernst-Moritz-Arndt-Universitt,
Greifswald, Germany
Sauerbruchstr./Bettenhaus I
17487 Greifswald, Germany
Phone: 0049 (0) 3834 86 7160
Fax:
0049 (0) 3834 86 7316
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2015
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ISBN 978-3-89756-122-9
Table of Contents
1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.0 Our Protocol for the Treatment

of TMJ Disc Displacements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.0 Diagnostic Arthroscopy of the Temporomandibular Joint . . . . . 8

3.1 Indications and Contraindications . . . . . . . . . . . . . . . . . . . . 8
3.2 Preoperative Preparations, Draping,|
and Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3.3 Arthroscopic Approach to the
Temporomandibular Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.4 Instrument Use, Description of Findings
and Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4.0 Minimally Invasive Arthroscopic Treatment of Disk
Displacement and Elongation of the Retrodiscal Tissue
Combined with Diagnostic Arthroscopy. . . . . . . . . . . . . . . . . . .
4.1 Shortening the Retrodiscal Tissue
with a Water-Jet Scalpel. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2 Aftercare and Complications
of Water-Jet Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3 Other Arthroscopic Treatment Options
(Nd:YAG and Holmium:YAG Lasers, Electrosurgery) . . . .
4.4 Arthroscopic Fixation Techniques |
An Additional Therapeutic Options . . . . . . . . . . . . . . . . . . .
4.5 TMJ Arthroscopy and Surgical|
Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
14
15
15
16
16
5.0 Arthroscopic Training in an Animal Model . . . . . . . . . . . . . . . . . . 17

6.0 The First Temporomandibular Joint Arthroscope
with an Integrated Working Channel
Advantages and New Technical Capabilities . . . . . . . . . . . . . . . .
18
7.0 Concluding Remarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

8.0 Recommended Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Instruments and Units for the
Arthroscopy of the Temporomandibular Joint . . . . . . . . . . . . . . . 23
1.0 Introduction
The surgical treatment of temporomandibular joint (TMJ)
disorders presents us with an extremely complex and
complicated set of interwoven problems that can raise
difficult issues of diagnosis and treatment.
The great diversity of TMJ disorders results from the
overlap between multiple organ systems and numerous
functional processes, as illustrated in Fig. 1.
As in all degenerative muscle, bone and joint diseases,

surgical intervention should be elected sparingly and
the primary treatment options are conservative. Surgical
treatment is indicated in only about 5% of patients
with TMJ disorders. Because TMJ operations are such
specialized procedures, often it takes years to acquire
adequate clinical experience.
Another factor that limits the indications for TMJ surgery
is the miniscule size of the joint (about the size of a
thumbnail). As a result, TMJ surgery and especially
minimally invasive arthroscopic procedures are more
technically demanding than procedures in larger joints,
which are easier to access and explore. A major obstacle
in mastering arthroscopic skills is the fact that operators
cannot practice in human patients, while practicing in
cadavers may do little to impart clinically relevant skills
due to the altered consistency and appearance of the
nonperfused tissues.
1
The temporomandibular joint and associated disorders.
The following components may also play a role:

Craniomandibular dysfunction (CMD)
Cerebral, neurological and psychiatric diseases
Orthopedic diseases (e.g., of the cervical spine)
Regulatory dysfunction, overloads, compensatory
processes
Age-related changes
Decompensation due to changes in activity level
or physical situation
Proper patient selection is an essential foundation for
successful surgical treatment. The principal indications
for TMJ surgery are forms of craniomandibular
dysfunction originating in the articular disc and
the retrodiscal tissue (known also as the posterior
attachment, posterior ligaments, or retrodiscal pad).
The literature may be consulted for further details on
these conditions.
At our institution in Greifswald, we have solved the

problem of safe TMJ arthroscopic training by developing
an animal model that enables us to practice and teach
a range of minimally invasive arthroscopic procedures
in the TMJ. This is such an effective training tool that
technical problems which subsequently arise in patients
no longer limit the indications for TMJ arthroscopy.
Our objective in creating this guide to TMJ arthroscopy
is to convey the experience that we have gained in
our training model. Besides the basic principles of
diagnostic arthroscopy, particular attention is given to
the arthroscopic use of an innovative water-jet scalpel
and to other arthroscopic techniques on the TMJ disc
and retrodiscal tissue.
The simultaneous use of a surgical navigation system
helps the operator to proceed more confidently and
will one day make an important contribution to quality
assurance in arthroscopic surgery of the TMJ.
In writing this monograph, we hope that we will be able
to improve training to such as degree that a greater
percentage of patients with TMJ disorders will become
candidates for arthroscopic surgery, thus avoiding
the large wounds of open surgical procedures and
perhaps eliminating the risk of facial nerve injury.
2.0 Our Protocol for the Treatment of TMJ Disc Displacements

TMJ disc displacements and elongation of the retrodiscal tissue referred to in the literature as internal
derangement, craniomandibular dysfunction, and
secondary or functional TMJ disorders (Gernet and
Rammelsberg 2002) account for more than 90% of
the TMJ cases that are referred to our center following
a trial of conservative therapy. Almost all of these cases
involve an anterior disc displacement with elongation of
the retrodiscal tissue. Rarely, we may see posterior disc
displacement in patients who have prognathic dentition
or an habitually protruded jaw posture. It is also rare to
encounter lateral disc displacements causing functional
problems, and so this booklet deals mainly with anterior
disc displacements with associated stretching of the
retrodiscal tissue.
Immediate manual reduction (aided by local anesthesia, intravenous sedation, or general anesthesia
with muscle relaxation).
Next: 3 months of conservative therapy (physical

therapy, determining and establishing the centric
position of the TMJ, splint therapy, pharmacologic
therapy).
After an unsuccessful 3-month trial of conservative therapy: reduction under arthroscopic control,
arthroscopic shortening of the retrodiscal tissue.
Conservative treatment is continued for up to one

year after arthroscopic surgery, including the use of
centric splints that protect the TMJ or widen the joint
space (e.g., a bite guard that moves the mandible
1.5 2 mm forward). Myoarthropathy may be treated
if necessary by injecting botulinum toxin into the
affected musculature (e.g., the lateral pterygoid
muscle).
Most chronic, non-reducing disc displacements begin

as an acute disc displacement. Thus, we repeatedly
emphasize the importance of avoiding progression to
more advanced stages of anterior disc displacement by
initiating adequate treatment while the displacement is
still in an acute stage.
With this in mind, we have developed a recommended
treatment protocol at our center, which is outlined below.
The guiding principle is that withholding treatment or
providing conservative treatment for an acute disc
displacement is appropriate only as long as the TMJ has
not sustained chronic, irreversible damage.
We apply the following protocol in the treatment of
acute, non-reducing anterior disc displacements at our
center. Note that the primary treatment measures are
conservative:
Permanent correction to a centric jaw position

(the painless or least painful position of the mandible)
should be considered at this stage as an alternative
to life-long splint therapy. Options for permanent
correction include orthognathic surgery, prosthetic
treatment, and dysgnathic surgery.
If the TMJ disorder has not improved or is worse by

12 months after the initial arthroscopic procedure,
we recommend further arthroscopic treatment
or even open surgery (e.g., open shortening of the
retrodiscal tissue)).
If the TMJ is not permanently corrected to a centric

position, it is extremely likely that the TMJ changes
will recur and that surgical measures on the disc and
retrodiscal tissue will be unsuccessful. We believe that
the timely initiation of appropriate treatment can reduce
the incidence of serious TMJ disorders.
3.0 Diagnostic Arthroscopy of the Temporomandibular Joint

3.1 Indications and Contraindications
3.2 Preoperative Preparations, Draping,|

and Instrumentation
The principal indications for TMJ arthroscopy are
functional complaints involving the TMJ in which clinical
examination and imaging studies have not furnished
a definitive diagnosis or non-invasive treatment
modalities have not significantly improved the patients
complaints.
Indications for arthroscopy:
Disc displacement
Disc deformity
Intra-articular adhesions
Degenerative arthritis
Osteoarthritis
Chronic forms of arthritis
Post-traumatic changes
Pseudotumors
Aseptic technique is a prime concern in TMJ arthroscopy. The patient should be draped in a manner
that provides sterile access to both TMJs and to the
puncture sites that will be marked on the skin. The
drapes should also allow free access for passive
opening and closing of the jaw by the operator. This is
best accomplished with a combination of sheets and
plastic film drapes (Fig. 2).
Prophylaxis of swelling and prophylactic antibiotics are
recommended in the perioperative period.
The instrumentation is illustrated and explained in the
Appendix.
Initial equipment and supplies needed for
diagnostic arthroscopy:

Arthroscopy is contraindicated in patients with acute

infections, bony ankylosis, risk of tumor dissemination,
general medical contraindications, and anatomical
contraindications (Blaustein and Heffez 1990, Murakami
1989, Ihnishi 1990, Reich 1995). Rigorous patient
selection is the key to a successful operation.
2
Draping for TMJ arthroscopy.

Skin marking pen

Ruler for drawing straight lines
Scalpel
Arthroscope sheath and trocar with sharp obturator
for creation of the working space / for access to the
site of surgery
Prepared irrigation liquid
3.3 Arthroscopic Approach to the

Temporomandibular Joint
The TMJ is approached through two trocars (ports),
each 2 mm in diameter. The HOPKINS telescope
(arthroscope) is introduced through one of the two
trocars, which also serves as an irrigation port. The
irrigation liquid is drained through the second trocar,
which also provides access for passing instruments to
the operative site.
Technique of TMJ Puncture for Diagnostic
Arthroscopy:
After the TMJ region has been palpated and inspected
and the position of the condylar head has been
determined by passive movement of the TMJ, the
trocar sites are marked using the method described by
Blaustain and Heffez (1990) and Reich (1995).
1 Locate and mark the center of the tragus.

2 Locate and mark the lateral canthus of the eye.
3 Draw a straight line between the center of the
tragus and the lateral canthus.

4 Measure and mark a point on the line that is
10 mm from the center of the tragus, and mark

a point (A) located 2 mm below it. The trocar
with obturator will be inserted at that point, and
the obturator will be removed for insertion of the
arthroscope.
5 Measure and mark a point on the original line that
is 20 mm from the center of the tragus. Drop a
perpendicular at that point, measure
10 mm down from the line, and mark that point
(B). That is the site where the trocar with sharp
obturator will be introduced (Fig. 3).
Before inserting the trocars, we palpate the TMJ region

and move the joint to confirm that the points have been
marked correctly, since some distortion may occur due
to shifting of the skin.
3
Planning the trocar sites for TMJ arthroscopy.
Puncturing the Joint:

At point A (Fig. 3): Insert the sharp obturator/trocar
assembly to the temporal bone, angling it medially
upward. While keeping the obturator tip in contact with
the bone, advance it approximately 2.5 cm into the upper
joint space, then remove the obturator.
Check the correct placement of the trocar in the joint
space by infusing irrigation fluid through the arthroscope
sheath (trocar) and passively opening and closing the
mandible. If the fluid level in the arthroscope sheath
moves with the jaw, this confirms that the trocar is safely
in the joint space. Now introduce the arthroscope with
attached video camera (remember to perform the white
balance!) into the sheath, and connect the irrigation line
to the arthroscope sheath.
At point B (Fig. 3): Insert the second sharp obturator
at point B with the tip of the obturator angled upward.
Direct it toward the tip of the arthroscope trocar and
advance it until it is in contact the temporal bone of
the glenoid fossa. Keeping the obturator tip in contact
with the bone, advance it approximately 2.5 cm into the
upper joint space, then remove the obturator.
Check the correct placement of the arthroscope sheath
in the joint space by infusing irrigation fluid through
the access port and passively opening and closing
the mandible. The fluid level in the arthroscope sheath
should move with the jaw, confirming that the sheath is
correctly positioned in the joint space.
10
Next open the inflow stopcock on the arthroscope

sheath, which is connected to an infusion system. If
continuous irrigation is obtained with an inflow pressure
of approximately 1000 mm H2O and there is a good
reflux of irrigation liquid through the sheath, an infusion
extension tubing can be connected to the arthroscope
sheath (to direct the fluid to a collection vessel), and
diagnostic arthroscopy may begin.
The outflowing fluid is collected in the vessel and may
be discarded or be retained for diagnostic testing. After
the operating room lights are turned off, the surgeon
proceeds with indirect diagnostic TMJ arthroscopy while
watching the video monitor.
Another technique for puncturing the upper joint space

is to use a blunt obturator after filling the upper compartment with fluid injected through a hypodermic needle.
To avoid injuring the disc and retrodiscal tissue, we track
the sharp point along the bone of the glenoid fossa,
working our way around the lateral rim of the fossa until
we feel the point fall into the joint space. Histologic
studies in animal models show that a fine scratch in the
bone of the lateral glenoid rim will heal completely with
no adverse sequelae for the joint.
Since distending the joint space with fluid may sometimes
result in a faulty puncture, an alternative method is to pull
the lower jaw forward and downward to open up the joint
space.
3.4 Instrument Use, Description of Findings and Documentation

First the video camera is rotated to a horizontal position
on the arthroscope to ensure proper horizontal alignment
of the arthroscopic image.
When a 30-HOPKINS forward-oblique telescope is
used, the viewing angle can be adjusted by rotating the
scope beneath the camera head. The advantage of using
a 30 scope is that it provides a larger viewing angle,
making it possible to visualize more of the joint. Care
is taken to keep the camera aligned in the horizontal
plane. Because working with a 30 scope is somewhat

more complicated than working with a 0-straight-ahead
scope, we recommend starting with the 0 scope, which
usually gives a satisfactory view (Figs. 4a, b).
Anterior-posterior orientation is checked by passively
opening and closing the jaw. When the mouth opens,
the disc moves anteriorly and the retrodiscal tissue
becomes more tense.
4a
4b
After introducing the arthroscope, the surgeon establishes orientation

in the TMJ by watching the video monitor while manually opening the
patients mouth.
11
If a red-out occurs during arthroscopy (Fig. 5), this

means that there is too much blood in the irrigating fluid
due to insufficient flow through the joint. The remedy is
to check and adjust the fluid inflow and outflow so that
adequate joint irrigation is maintained by the system
inflow pressure alone. When this has been accomplished,
the field should clear and the intra-articular structures
should reappear in the image.
At most institutions, the classification of TMJ disc
displacements has been based on clinical findings such
as incisal edge clearance and the degree of displacement
shown by magnetic resonance imaging.
However, experience in surgical patient groups has
shown that the preoperative classification often does not
correlate with the arthroscopic findings and the pattern
of complaints. It seems preferable, therefore, to classify
disc displacements on the basis of arthroscopic findings.
The following points should be noted:
1 Landmarks are needed for recognizing and
5
Arthroscopic red-out due to insufficient lavage.
classifying disc displacement.

2 It should be possible to define and evaluate
the landmarks simultaneously in the same

arthroscopic field.
3 For taking measurements, it would be helpful to
project a scale or grid into the arthroscopic image
that relates directly or indirectly to actual
dimensions.
4 Mouth opening should be taken into account,
since the displacement depends on the degree of
mouth opening. For reproducibility, disc position
should always be determined at equal degrees of
incisal edge clearance.
Two useful landmarks are the usually well-defined

junction between the disc and retrodiscal tissue and
the most caudal (lowest) point of the articular tubercle.
It is not always possible to define both landmarks
simultaneously in the arthroscopic field. But nonvisualization of the junction between the disc and retrodiscal
tissue can itself be used as a classification criterion
(see below). Based on my research of the literature,
the problem of projecting a measurement scale into

the arthroscopic image has not yet been solved, and
so the arthroscopic classification of disc displacement
continues to be a subjective assessment that is not
entirely reproducible. Surgical navigation may be the
key to eliminating the subjective factor (see Chapter
4.5). The most reproducible way to take into account
mouth opening is by classifying the disc displacement
in the closed-mouth and maximum open-mouth
positions.
Arthroscopy can be used to stage the morphological
changes in the TMJ. This is helpful both in making
a prognosis and in selecting patients for further
treatment.
Arthroscopic staging is based on the degree of
disc displacement and the degree of changes in the
retrodiscal tissue in relation to the articular tubercle.
As explained below, we classify anterior disc
displacements into three stages, each of which has
associated therapeutic and prognostic implications.
12
6
Arthroscopic view of a stage I disc displacement.
Classification of disc and retrodiscal changes by

TMJ arthroscopy, taking into account the degree of
mouth opening (closed-mouth and maximum openmouth positions):
Stage I anterior disc displacement (Fig. 6): The disc
shows a slight degree of anterior displacement (with
reduction) when the mouth is closed. At maximum
mouth opening the disc is still below the tubercle, and
there is little if any limitation of disc gliding (and thus of
mouth opening). The retrodiscal tissue is elongated and
its function is impaired (see also Fig. 9a).
As Fig. 6 illustrates, the two most important regions
for evaluating TMJ disease (the retrodiscal region and
disc-tubercle region) cannot always be seen in the same
image due to the 1.9-mm diameter of the arthroscope. In
this case the regions must be evaluated separately and
are then correlated to interpret the images.
Stage II anterior disc displacement (Fig. 7): Only
a small, posterior portion of the disc is still below the
tubercle at maximum mouth opening, and there is
significant limitation of disc gliding (and mouth opening).
The retrodiscal tissue is moderately elongated and its
function is impaired.
7a
7b
7c
Arthroscopic view of a stage II disc

placement. The junction of the disc and
retrodiscal tissue is below the tubercle;
normally it should lie farther back in the
joint.
View of the articular tubercle and underlying

disc (a, b).
View of the hyperplastic retrodiscal tissue (c).
13
Stage III anterior disc displacement (Fig. 8): The disc

is anterior to the tubercle when the mouth is maximally
opened, and there is a complete or almost complete
limitation of disc gliding (and mouth opening). The
retrodiscal tissue is markedly elongated, and its function
is profoundly impaired.
Figure 9a shows various degrees of retrodiscal tissue
changes that correlate with the three stages of anterior
disc displacement. The stages of disc displacement
illustrated by the arthroscopic images in Figs. 68 are
shown schematically in Fig. 9b.
The arthroscopic images should be documented
on videotape, video printouts, or digital media for
permanent archiving. If desired, the images may be
written onto a CD for viewing by the patient or the next
attending physician.
Stage I and stage II disc displacements are indications
for arthroscopic shortening of the retrodiscal tissue,
with a good long-term prognosis. Stage III displacement can be treated arthroscopically with a guarded
long-term prognosis, and poor responders can be
referred for further surgical treatment.
8
Arthroscopic view of a stage III disc displacement. The elongated
retrodiscal tissue is below the tubercle, and the disc lies anterior to
the condylar head and tubercle.
Stage I
Stage II
Stage III
9a
9b
Arthroscopic appearance of the retrodiscal tissue and medial

articular surface at various stages of disc displacement and
associated hyperplasia and elongation of the retrodiscal tissue.
Schematic representation of the stages of anterior disc displacement.
14
4.0 Minimally Invasive Arthroscopic Treatment of Disk|

Displacement and Elongation of the Retrodiscal Tissue|
Combined with Diagnostic Arthroscopy
4.1 Shortening the Retrodiscal Tissue with a Water-Jet Scalpel
TMJ disorders are becoming an increasingly widespread
problem in our society. The most common disorders
involve an elongation of the retrodiscal tissue combined
with anterior disc displacement. Surgical treatment is
indicated for particularly severe cases that have not
been adequately managed by conservative therapy.
The primary goal of surgical treatment is to improve
the function of the retrodiscal ligaments and prevent
functionally significant disc displacement.
In an open surgical approach, this is accomplished
by excising a portion of the retrodiscal tissue and
reapproximating it with sutures to tie back the disc. It
is desirable to correct the retrodiscal tissue and reduce
the articular disc by means of a minimally invasive
arthroscopic procedure. Scarring can be induced in
the TMJ endoscopically by creating a surgical wound
in the retrodiscal tissue. This led to the idea of using
a water-jet scalpel arthroscopically to shorten the
retrodiscal tissue.
10
Shortening the retrodiscal tissue with a water-jet scalpel:
a Locating the retrodiscal tissue,
b Appearance after treatment with the water-jet scalpel.
The water jet causes the retrodiscal tissue to swell, producing
an immediate shortening effect. This effect is perpetuated by
subsequent scarring of the tissue.
The rationale of this procedure is to shorten and tighten

the posterior ligaments as a means of returning the
articular disc to its original anatomical position (Kaduk
et al. 2005).
While a simple diagnostic arthroscopy without tissue
sampling requires only an arthroscope port and a fluid
drainage port, retrodiscal surgery additionally requires
that a port for operating instruments be placed precisely
at the operative site in the TMJ. This triangulation
technique has a relatively high degree of technical
difficulty and takes a considerable amount of practice
to learn. In triangulation, the tip of the arthroscope port
is placed in the upper joint space so that the working
space can be created under arthroscopic guidance via
the video monitor. The best point in the retrodiscal tissue
for treatment with the water-jet scalpel is the junction
between its anterior and middle thirds. When the arthroscope sheath has been placed, the water-jet scalpel is
introduced into the operating channel, and that portion
of the retrodiscal tissue is treated from medial to lateral
at a pressure of 60 bar (Fig. 10). Next the function of the
disc and retrodiscal tissue is checked arthroscopically at
rest and during passive movement of the lower jaw.
Owing to the excellent biocompatibility of the cutting
medium (water), the low degree of tissue necrosis, and
the excellent control of the water-jet cutting intensity,
which is continuously adjustable from 1 to 150 bar, we
prefer the water-jet scalpel marketed by Erbe Elektromedizin, Tbingen, Germany. Another advantage of
the variable jet intensity is the ability to apply selective
pressure treatment to pain receptors in the retrodiscal
tissue (similar to acupressure). If the dominant symptom
is pain, the water-jet treatment will at least interrupt the
vicious cycle and improve the patients complaints.
15
4.2 Aftercare and Complications of Water-Jet Treatment

Key issues following arthroscopy are the correct
assessment of findings and the decision-making for
further management.
We recommend postoperative immobilization with a
head-and-chin dressing for 2 days, a soft diet for 2
weeks, no excessive mouth opening or stresses for
4 weeks, and continued supportive management
with splints and physical therapy. Subsequent
treatment depends on the course or progression of the
disorder (see our treatment protocol for anterior disc
displacement in Chapter 2).
Postoperative swelling about the TMJ occasionally
leads to obstruction of the Eustachian tube accompanied by transitory hearing impairment.
Pressure on the posterior trocar may cause it to bend

backward and damage the external auditory canal. Very
rarely, this may cause fractures and fine cracks in the ear
canal, similar to those occasionally seen in association
with subcapital fractures of the mandibular condyle.
These injuries are treated with an antibiotic-impregnated
ointment packing until they are completely healed.
Other complications of arthroscopic surgery have been
reported in the literature, but so far we have not encountered them at our institution: penetration of the middle
cranial fossa, cerebral injuries, and injuries to the middle
ear, inner ear, or facial nerve. All of these potential
complications and problems should be disclosed to the
patient during the informed consent discussion.
4.3 Other Arthroscopic Treatment Options

(Nd:YAG and Holmium:YAG Lasers, Electrosurgery)
Some authors (Mosby 1993, Murakami et al. 1996)
state that arthroscopic irrigation alone can produce
a permanent therapeutic effect in properly selected
patients. Pain relief in these cases is often associated
with improved clinical findings such as increased mouth
opening, decreased crepitus, or both.
The goal of arthroscopic surgical treatment is to augment
or achieve this effect through specific measures in the
TMJ.
Besides the water-jet scalpel, a Nd: YAG or holmium:
YAG laser can be used to induce scarring and shortening
of the retrodiscal tissue (Fig. 11). The laser energy is
delivered directly to the retrodiscal tissue through an
optical fiber passed through the working channel into
the TMJ. A similar technique is used with electrosurgical
cutting and cautery instruments.
11
Use of the Nd:YAG laser (arrow) in the TMJ.
16
4.4 Arthroscopic Fixation Techniques |

An Additional Therapeutic Options
If the water-jet treatment alone is insufficient, the
retrodiscal tissue can be fixed with an absorbable
polylactide screw as another alternative to open surgery
(Fig. 12). Generally, however, we allow approximately 1
year for the water-jet scar to mature before concluding
that it has been unsuccessful and further treatment is
needed. Based on our studies in the porcine TMJ, the
polylactide screw induces considerably more scarring
in the retrodiscal tissue than the water-jet scalpel alone,
without causing other clinically significant side effects
(Kaduk et al. 2002). This technique should be reserved
for experienced TMJ surgeons, and rigorous patient
selection criteria should be applied. Similar techniques
are used for arthroscopic surgery of the knee ligaments
and menisci, for example.
4.5 TMJ Arthroscopy

and Surgical|Navigation
At present there are three reasons why a surgical
navigation system could contribute to the improvement
of arthroscopic surgical technique:
12
Shortening the retrodiscal tissue with a polylactide screw.
(a, b): Treatment with the water-jet scalpel. (c): Polylactide
screw insertion in the preauricular connective tissue.
1 It allows a more objective arthroscopic
diagnosis and improves the correlation between

MRI and arthroscopic findings.
2 Facilitating the puncture and triangulation
technique (see Chapter 4.1).
3 It can direct the insertion of polylactide screws
and other arthroscopic fixation devices.
The successful use of a navigation system depends
critically on the precision of preoperative imaging and
on a precise registration of the patient with navigation
software, which currently has an accuracy of 1.5 mm.
13
Correlation between MRI and arthroscopy with a surgical navigation
system.
17
5.0 Arthroscopic Training in an Animal Model

In the past, human cadaver studies and visiting physician
programs were the only means available for learning
arthroscopic surgery in patients. But practice in human
cadavers is of limited value due to postmortem tissue
changes, which are present even in unfixed specimens.
There is little or no opportunity for interpreting
arthroscopic findings, evaluating tissue blood flow, or
differentiating between normal findings and pathologic
changes.
Visiting physician programs are also limited in their
ability to provide adequate operating room experience.
It is difficult to justify the time-consuming practicing of
triangulation techniques and instrument manipulations
in actual patients.
I have found that practice in an animal model is
essential for acquiring independent arthroscopic
operating experience without running the risk of a higher
complication rate. Through repeated practice in such
a model, the operator will learn to use the arthroscope
Arthroscopic approach to the porcine TMJ

(trocar sites have been marked on the skin).
14
so proficiently that he or she can ultimately perform

successful arthroscopic surgery in human patients.
A model is also an indispensable tool for the advancement of arthroscopic operating techniques.
In our search for a suitable model for TMJ arthroscopy,
we were able to develop a technique in the porcine jaw
(Kaduk et al. 2003). We have found that arthroscopic
images of the human and porcine TMJ are visually
indistinguishable from each other, indicating that this
species is an excellent model for arthroscopic exercises
and examinations in the TMJ. The only difference
between the human and porcine TMJ is the location of
the access ports. Once the upper joint space has been
entered, there are no appreciable differences between
the human TMJ and our animal model. Figure 14 shows
the placement of the trocar sites about the porcine
TMJ. All further steps in diagnostic arthroscopy and
arthroscopic surgery of the retrodiscal tissue are the
same as previously described (see Chapter 3).
18
6.0 The First Temporomandibular Joint Arthroscope

with an Integrated Working Channel
Advantages and New Technical Capabilities
The most difficult and time-consuming step in
arthroscopic procedures on the temporomandibular
joint (TMJ) is triangulation, i.e., locating the working
channel with the endoscope and then navigating both
the working channel and arthroscope through the joint
space so that surgical actions can be performed in the
joint space under endoscopic vision. These actions
may include biopsies, the removal of intra-articular
loose bodies, endoscopic hydrodissection or laser use
(Figs. 15a, b), endoscopic suture techniques, and other
bimanual arthroscopic procedures within the TMJ.
By interviewing participants at the TMJ arthroscopy
workshop held each year at the University of Greifswald,
we know that the problem of triangulation is one of
the main reasons why the participants do not go on to
practice TMJ arthroscopy on their own after completing
the workshop.
The new TMJ arthroscope from KARL STORZ solves

the triangulation problem by combining the endoscope
and working channel in one device. This eliminates the
often-tedious process of locating the working channel
for a number of applications (Fig. 15c).
From a practical standpoint, this means that the operator
can look through the arthroscope while simultaneously
manipulating instruments through the working channel
under arthroscopic guidance. With an outer diameter of
2.3 mm and an integrated working channel of 1.1 mm,
the new endoscope conforms to the known anatomic
dimensions of the TMJ. The optical fibers that transmit
the arthroscopic image are arranged about the circumference of the working channel (Fig. 15c).
15a
15b
15c
A water-jet scalpel (third generation

Hydro-Jet dissector, Erbe, Tbingen,
Germany) can be introduced through the
integrated working channel of the new
arthroscope (KARL STORZ GmbH & Co. KG,
Tuttlingen; see Fig. 15c).
Nd:YAG laser (Martin) with optical fiber

beam delivery. The laser fiber can be
introduced through the working channel
of the new arthroscope.
TMJ arthroscope with integrated working

channel. Here a water-jet applicator with
a 100-micron lumen has been introduced
through the working channel for use on the
retrodiscal tissue of the TMJ.
19
The first TMJ arthroscope with an integrated working

channel was produced by KARL STORZ in 2009. The
system was initially tested in experimental animals under
1 Is the new arthroscope stable enough to pierce the
TMJ capsule and meet the functional requirements

of TMJ arthroscopy?
2 Is the handling of the arthroscope satisfactory,
and is the outer diameter of the endoscope small

enough for insertion into the joint?
3 Is the endoscopic image resolution or video
quality adequate for evaluating the TMJ and guiding

instrument use within the joint space?
The results of the experimental studies have shown

that the TMJ arthroscope with integrated working and
irrigation channels does have adequate stability, despite
the fact that its outer diameter is limited to 2.3 mm by
anatomical constraints. Even when piercing the TMJ
capsule, the arthroscope showed no instability or other
design-related problems. The 2.3-mm outer diameter
could enter the joint space as easily as a conventional
arthroscope with an outer diameter of 2.0 mm.
Because the arthroscope shaft, with its 2.3-mm diameter,
had to accommodate the integrated working channel in
addition to optical fibers, the number of optical fibers
general anesthesia (Kaduk et al. 2003) with the goal of

answering the following questions:
4 Can the integrated irrigation channel provide for
continuous irrigation of the joint space?

5 Does the integrated working channel of the
new TMJ arthroscope allow for the easy,
precise handling and guidance of instruments
(probe, laser fiber, water-jet scalpel)?
6 Can the new endoscope be maneuvered through
the joint space by surgical navigation, for example,
and are all intra-articular structures accessible via
the arthroscope?
had to be reduced to make room for the extra channel.

As a result, the resolution of the new device is less than
that of traditional TMJ arthroscopes. The decreased
resolution did not prove to be a problem during practical
work with the arthroscope, however. As Fig. 16ac
illustrates, the image quality is fine for evaluating the
intra-articular structures and using instruments through
the integrated working channel.
Irrigating the joint at a pressure of 1000 mm H2O with an
infusion system was sufficient to maintain a clear image
throughout the procedure.
16a
16b
16c
View of a human right TMJ using the

arthroscope with integrated working
channel. The image shows the
posterosuperior junction of the retrodiscal
tissue with the synovial membrane.
Water-jet applicator aimed at the retrodiscal

tissue of the TMJ.
Nd:YAG laser fiber with pilot beam (arrow)

aimed at the junction of the first and second
thirds of the retrodiscal tissue.
20
17
The handling of the arthroscope was excellent. Because

the use of a laser fiber or water-jet scalpel no longer
requires a second portal for the working channel and
does not require triangulation, the procedure time was
shortened by more than 50%. An arthroscope with an
integrated working channel significantly reduces the
technical difficulty of TMJ arthroscopy (Fig. 17).
The new configuration of the endoscope and its
increased length allow it to be fitted with a navigation
antenna (BrainLAB). Digital tomographic volume data
sets, for example, can be used to navigate through the
joint, providing even better guidance of arthroscope
insertion and positioning within the joint space (Fig.
18) and adding new research capabilities for the further
advancement of arthroscopy.
Because arthroscopic procedures no longer require a
second portal for the working channel in cases where
the working instrument can fit through the 1.1-mm
integrated working channel, it is reasonable to assume
that TMJ arthroscopy can be performed even less
invasively with less pain and trauma to the joint.
After the TMJ arthroscope with integrated working
channel had been tested in animal studies, we began
using it in patients in September of 2009.
Consistent with our experimental findings, we confirmed
that TMJ arthroscopy could be performed in patients
much more easily with the new instrument. This results in
a much shorter learning curve for maxillofacial surgeons
who are new to the procedure.
Handling of the TMJ arthroscope with integrated working channel

(model 11578 A, KARL STORZ GmbH & Co. KG, Tuttlingen,
Germany). Here the Hydro-Jet applicator is being advanced into the
joint. The TMJ disc and articular tubercle are visible on the monitor.
The static image displayed on the video monitor (taken during TMJ
arthroscopy in a human patient) shows the articular disc positioned
directly beneath the left articular tubercle.
18
Three-dimensional CT image displays the close anatomic relationship
among the TMJ, the external auditory canal, and the middle and inner
ear. This underscores the potential value of navigation-assisted TMJ
arthroscopy in preventing complications.
The TMJ arthroscope with integrated working channel

offers advanced technical possibilities for arthroscopic
surgery. For example, it is conceivable that two of these
endoscopes could be introduced into the joint space to
facilitate arthroscopic suturing techniques. Moreover, the
integrated working channel provides enhanced technical
21
capabilities that could be useful for other applications

in oromaxillofacial surgery, facial plastic surgery, and
otorhinolaryngology such as paranasal sinus endoscopy.
The inherently larger endoscope diameter also helps to
simplify design and manufacturing.
7.0 Concluding Remarks

Practice operations in the animal model have yielded
the important discovery that beginners in particular
must exercise a great deal of patience when locating
and placing the arthroscope sheath (triangulation
technique) in order to achieve the goal of the arthroscopic procedure. The new TMJ arthroscope, with its
integrated working channel, can alleviate this problem
by limiting the need for triangulation to procedures that
require instrument diameters larger than 1.1 mm and
specialized techniques. A second important insight is
the need to stay in contact with the bone of the glenoid
fossa when introducing the arthroscope into the upper
joint space. We have found that when this rule is ignored,
the arthroscopy invariably fails. This can lead to disc
perforations and retrodiscal injuries that are extremely
difficult to repair. When work in patients is deferred
until the operator has gained adequate experience with
TMJ arthroscopy in the animal model, the complication
rate is correspondingly low.
Since neither cadaver training nor visiting physician
programs can provide adequate experience, we
supplement arthroscopic training in the porcine TMJ
with the study of human TMJ specimens in order to

close this gap both for clinicians in training and for
clinical researchers.
This course of training may then be followed by a visiting
physician program and independent clinical work. We
recommend that visiting physicians do their rotation
individually with personal supervision rather than in
groups. When arthroscopic shortening of the retrodiscal
tissue with a water-jet scalpel (see Chapter 4.1) becomes
an established technique, it will be possible to select
patients for surgical treatment at a considerably earlier
stage.
Another aspect is that the traditional policy of restraint
based on concerns about the risks of open TMJ surgery
need no longer prevail until the distress experienced by
patients justifies the higher complication rate of open
surgery.
In any case, a disorder of the masticatory muscles
(myopathy) is always closely related to arthropathy and
usually represents the primary and limiting disorder in
the treatment of temporomandibular joint dysfunction.
22
8.0 Recommended Reading

1. BLAUSTEIN DI, HEFFEZ LB (1990): Arthroscopic
Atlas of the Temporomandibular Joint.
Lea & Febiger, Philadelphia, London
2. GERNET W, RAMMELSBERG P (2002):
Kiefergelenkerkrankungen und Funktionsstrungen.
In: Schwenzer, N., Ehrenfeld, M. (Hrsg.) Zahn-MundKieferheilkunde. Bd. 3 Zahnrztliche Chirurgie,
Thieme, Stuttgart, 263310
3. KADUK WMH, HANSCHKE M, SMNIG W,
METELMANN HR (2002): The arthroscopic dorsal
ligament plasty at the TMJ with absorpable
polylaktid-arrow (Diskarrow) in pigs. Development
and prooftesting of a new surgical method.
J Cranio-Maxillofac Surg 30/1, 236
4. KADUK WMH, METELMANN HR, GUNDLACH KKH
(2003): Das Landschwein als Modell fr Ausbildung,
wissenschaftliche Untersuchungen und Entwicklung
neuer arthroskopischer Operationsmethoden am
Kiefergelenk. Mund Kiefer Gesichtschir 4:235240
5. KADUK WMH, WOLF E, METELMANN HR (2005):
Arthroskopische dorsale Kiefergelenkbandstraffung
mittels Wasserstrahlskalpell. Eine experimentelle
Studie am Landschwein. Mund Kiefer Gesichtschir
9:2935
6. Kaduk WMH, Podmelle F (2010): Advantages and
new possibilities by implementation of the first TMJ
arthroscope with integrated working channel into
endoscopic surgery. In: Selected papers from the
twentieth congress of the European Association of
Cranio-Maxillo-Facial Surgery. Editor: Mommaerts,
MY, Medimont, Bruges, 2010, 347-353
(ISBN 978-88-7587-581-7)
7. McCAIN JP et al. (1991): Puncture technique and

portals of entry for diagnostic and operative
arthroscopy of the temporomandibular joint.
Arthroscopy 7(2):22132
8. MOSBY E (1993): Efficacy of temporomandibular
joint arthroscopy: a retrospective study.
J Oral Maxillofac Surg 51: 1721
9. MURAKAMI K (1989): Arthroscopic technique.
In: Sanders B, Murakami KI, Clark GT (eds)
Diagnostic and surgical arthroscopy of the
temporomandibular joint. Saunders, Philadelphia,
pp 6072
10. MURAKAMI K, MORIYA Y, GOTO K (1996):
Four year follow-up study of temporomandibular joint
arthroscopic surgery for advanced stage internal
derangements. J Oral Maxillofac Surg 54: 285-290
11. OHNISHI M (1990): Arthroscopy and arthroscopic
surgery. In: De Burgh Norman J-E, Bramley P, (eds)
A textbook and colour atlas of the temporomandibular
joint. Diseases disorders surgery. Wolfe, London,
pp 110128
12. REICH RH (1995): Kiefergelenkchirurgie. In:
Kirschnersche Operationslehre Bd.II, MundKiefer-Gesichtschirurgie Hrsg.: Hausamen, J.-E.,
Machtens, E., Reuther, J., Springer, Berlin 1995,
181210
Instruments and Units for the

23
24
Basic Set for Arthroscopy of the Temporomandibular Joint, consisting of:

58705 AA
HOPKINS Straight Forward Telescope 0, diameter 1.9 mm, length 6.5 cm,
autoclavable, fiber optic light transmission incorporated, color code: green
58706 AN
High Flow Arthroscope Sheath, diameter 2.5 mm, working length 4 cm,
for use with HOPKINS Telescope 0, 58705 AA, color code: green
58705 BA
HOPKINS Forward-Oblique Telescope 30, diameter 1.9 mm, length 6.5 cm,
autoclavable, fiber optic light transmission incorporated, color code: red
58706 BN
High Flow Arthroscope Sheath, diameter 2.5 mm, working length 4 cm,
for use with HOPKINS Telescope 30, 58705 BA, color code: red
58706 BS
Obturator, sharp, for use with Arthroscope Sheaths 58706 AN/BN
58706 BT
Obturator, blunt, for use with Arthroscope Sheaths 58706 AN/BN
58717 X
Trocar, diameter 1.8 mm, length 4 cm, for use with 58717 XB/XS
58717 XS
Obturator, sharp, for use with|Trocar|58717 X
58717 XB
Obturator, blunt, for use with|Trocar|58717 X
58717 PZ
Biopsy Forceps, single-action jaws, diameter|1.3|mm, length 6 cm
58702 EO
Scissors, upbiting, diameter 2 mm, working length 10 cm
58702 EK
Scissors, downbiting, diameter 2 mm, working length 10 cm
58702 DH
Forceps, through-cutting, diameter 2 mm, working length 10 cm
58702 U
Grasping Forceps, diameter 2 mm, working length 10 cm
58702 M
Knife, bayonet-shaped, diameter 1.5 mm, working|length 7.5 cm
58702 N
Sickle Knife, diameter 1.5 mm, working|length 7.5 cm
58702 S
Palpation Hook, graduated, diameter 1.5 mm, length of hook 1 mm,

working length 7.5 cm
58702 W
Changing Rod, for sheaths and trocars, length 15 cm
58702 X
Trocar, diameter 2.5 mm, length 3.5 cm, for use with instruments 58702 M/N/S
58702 XS
Obturator, sharp, for use with Trocar|58702 X
58702 XT
Obturator, blunt, for use with Trocar|58702 X
It is recommended to check the suitability of the product for the intended procedure prior to use.
25
Basic Set for Arthroscopy of the Temporomandibular Joint
58705 AA
58705 BA
HOPKINS Straight Forward

Telescope 0,
diameter 1.9 mm, length 6.5 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: green
HOPKINS Forward-Oblique
Telescope 30,
diameter 1.9 mm, length 6.5 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: red
58706 AN
High Flow Arthroscope Sheath,

diameter 2.5 mm, working length 4 cm,
for use with HOPKINS Telescope 0,
58705 AA, color code: green
58706 BS
Obturator, sharp, for use with Arthroscope

Sheaths 58706 AN/BN
58706 BT
Obturator, blunt, for use with Arthroscope

Sheaths 58706 AN/BN
58706 BN
High Flow Arthroscope Sheath,

diameter 2.5 mm, working length 4 cm,
for use with HOPKINS Telescope 30,
58705 BA, color code: red
58706 BS
Obturator, sharp, for use with Arthroscope

Sheaths 58706 AN/BN
58706 BT
Obturator, blunt, for use with Arthroscope

Sheaths 58706 AN/BN
26
58717 X
Trocar, diameter 1.8 mm, length 4 cm,

for use with 58717 XB/XS
58717 XS
Obturator, sharp,
for use with Trocar|58717 X
58717 XB
Obturator, blunt,
for use with Trocar|58717 X
58702 X
Trocar, diameter 2.5 mm, length 3.5 cm,

for use with instruments 58702 M/N/S
58702 XS
Obturator, sharp,
for use with trocar|58702 X
58702 XT
Obturator, blunt,
for use with trocar|58702 X
27
58717 PZ
58702 EO
Scissors, upbiting, diameter 2 mm,

working length 10 cm
58702 EK
Scissors, downbiting, diameter 2 mm,

58702 DH
Forceps, through-cutting, diameter 2 mm,

58702 U
Grasping Forceps, diameter 2 mm,

58717 PZ
Biopsy Forceps, single-action jaws,

diameter|1.3|mm, length 6 cm
58702 N
Sickle Knife, diameter 1.5 mm,

working|length 7.5 cm
58702 M
Knife, bayonet-shaped, diameter 1.5 mm,

working|length 7.5 cm
58702 S
Palpation Hook, graduated, diameter 1.5 mm,

length of hook 1 mm, working length 7.5 cm
58702 W
Changing Rod, for sheaths and trocars,

length 15 cm
28
ALL-IN-ONE Temporomandibular Joint Arthroscope and Instruments
11578 A
Miniature Straight Forward Telescope 0,

diameter 2.2 mm, working length 65 mm, autoclavable,
working channel 1.4 mm, irrigation channel 0.25 mm,
with remote eyepiece and fiber optic light transmission incorporated,
for use with Trocar 11578 KA
11578 BS
Obturator, sharp,
for use with Trocar 11578 KA
Same, blunt
11578 BT
11578 KA
Trocar, outer diameter 2.6 mm,

working length 6.5 cm, graduated,
for use with Telescope 11578 A
and Obturators 11578 BS/BT
29
ALL-IN-ONE Temporomandibular Joint Arthroscope and Instruments
11580 B
11578 PZ
Biopsy Forceps, semirigid,

diameter 1.3 mm,
working length 20 cm,
for use with ALL-IN-ONE
TMJ Arthroscope 11578 A
11578 EO
Scissors, semirigid,
diameter 1.3 mm,
11578 S
Palpation Hook, graduated,

Metal Tray, for sterilization and storage of one Miniature Straight

Forward Telescope 11575 A, 11581 A, 11582 A or 11583 A,
11578 A, perforated, lid with silicone bridges, with port for irrigation
connector, external dimensions (w x d x h): 275 x 178 x 35 mm
30
IMAGE 1 SPIES Camera System n

Economical and future-proof
Modular concept for flexible, rigid and
3D endoscopy as well as new technologies
Forward and backward compatibility with video
endoscopes and FULL HD camera heads
Innovative Design
Dashboard: Complete overview with intuitive
menu guidance
Live menu: User-friendly and customizable
Intelligent icons: Graphic representation changes
when settings of connected devices or the entire
system are adjusted

Sustainable investment
Compatible with all light sources
Automatic light source control

SPIES VIEW: Parallel display of standard image
and the SPIES mode
Multiple source control: IMAGE 1 SPIES allows
the simultaneous display, processing and
documentation of image information from
two connected image sources, e.g., for hybrid
operations
Dashboard
Live menu
Intelligent icons
SPIES VIEW: Parallel display of standard image and SPIES mode
31

Brilliant Imaging
Clear and razor-sharp endoscopic images in
FULL HD
Natural color rendition

Reflection is minimized
Three SPIES technologies for homogeneous
illumination, contrast enhancement and color
shifting
FULL HD image
SPIES CLARA
FULL HD image
SPIES CHROMA
FULL HD image
SPIES SPECTRA A
FULL HD image
SPIES SPECTRA B
32
TC 200EN
TC 200EN*
IMAGE 1 CONNECT, connect module, for use with up to

3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 120 VAC/200 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU
Specifications:
HD video outputs
- 2x DVI-D
- 1x 3G-SDI
Power supply
100 120 VAC/200 240 VAC
Power frequency
50/60 Hz
Format signal outputs
1920 x 1080p, 50/60 Hz
Protection class
I, CF-Defib
LINK video inputs
3x
Dimensions w x h x d
305 x 54 x 320 mm
USB interface
SCB interface
4x USB, (2x front, 2x rear)

2x 6-pin mini-DIN
Weight
2.1|kg
For use with IMAGE 1 SPIES

IMAGE 1|CONNECT Module TC 200EN
TC 300
TC 300
IMAGE 1 H3-LINK, link module, for use with

IMAGE 1 FULL HD three-chip camera heads,
power supply 100 120 VAC/200 240 VAC, 50/60 Hz,
for use with IMAGE 1 CONNECT TC 200EN
including:
Link Cable, length 20 cm
Specifications:
Camera System
TC 300 (H3-Link)
Supported camera heads/video endoscopes
TH 100, TH 101, TH 102, TH|103,|TH|104, TH 106

(fully SPIES-compatible)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without SPIES function)
LINK video outputs
1x
Power supply
100 120 VAC/200 240 VAC
Power frequency
50/60 Hz
Protection class
I, CF-Defib
305 x 54 x 320 mm
Weight
1.86 kg
33
IMAGE 1 SPIES Camera Heads n
For use with IMAGE 1 SPIES camera system

IMAGE 1|CONNECT Module TC 200EN, IMAGE 1 H3-LINK Module TC 300
and with all IMAGE 1 HUB HD Camera Control Units
TH 100
TH 100
IMAGE 1 H3-Z SPIES Three-Chip FULL HD Camera Head,

50/60 Hz, SPIES compatible, progressive scan, soakable,
gas- and plasma-sterilizable, with integrated Parfocal Zoom
Lens, focal length f = 15 31 mm (2x), 2 freely programmable
camera head buttons, for use with IMAGE 1 SPIES
and IMAGE 1 HUB HD/HD
Specifications:
IMAGE 1 FULL HD Camera Heads
H3-Z SPIES
Product no.
TH 100
Image sensor
3x 1/3" CCD chip
39 x 49 x 114 mm
Weight
270 g
Optical interface
integrated Parfocal Zoom Lens,

f = 1531 mm (2x)
Min. sensitivity
F 1.4/1.17 Lux
Grip mechanism
standard eyepiece adaptor
Cable
non-detachable
Cable length
300 cm
TH 104
TH 104
IMAGE 1 H3-ZA SPIES Three-Chip FULL HD Camera Head,

50/60 Hz, SPIES compatible, autoclavable, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 31 mm (2x),
2 freely programmable camera head buttons, for use with
IMAGE 1 SPIES and IMAGE 1 HUB HD/HD
Specifications:
IMAGE 1 FULL HD Camera Heads
H3-ZA SPIES
Product no.
TH 104
Image sensor
3x 1/3" CCD chip
39 x 49 x 100 mm
Weight
299 g
Optical interface
integrated Parfocal Zoom Lens,

f = 1531 mm
Min. sensitivity
F 1.4/1.17 Lux
Grip mechanism
standard eyepiece adaptor
Cable
non-detachable
Cable length
300 cm
34
Monitors
9619 NB
19" HD Monitor,
color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord
9826 NB
26" FULL HD Monitor,

color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image format 16:9,
power supply 100 240 VAC, 50/60 Hz
including:
Mains Cord
9627 NB
27" FULL HD Monitor,

color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image format 16:9,
power supply 85 265 VAC, 50/60 Hz
including:
Mains Cord
9627 NB-2
Same, with double video inputs
9619 NB
9826 NB
9627 NB/NB-2
35
Monitors
KARL STORZ HD and FULL HD Monitors
27"
19"
26"
9619 NB
9826 NB
DVI-D
OO
Fibre Optic
optional
optional
3G-SDI
optional
O
O
O
O
O
O
O
RGBS (VGA)
O
O
O
OO
OO
OO
O
O
O
O
O
O
Wall-mounted with VESA 100 adaption
9627 NB
9627 NB-2
Inputs:
S-Video
Composite/FBAS
Outputs:
RGBS (VGA)
O
O
O
O
3G-SDI
optional
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
DVI-D
S-Video
Composite/FBAS
Signal Format Display:

4:3
5:4
16:9
Picture-in-Picture
PAL/NTSC compatible
Optional accessories:
9826 SF
Pedestal, for monitor 9826 NB
9626 SF
Pedestal, for 96xx monitor series
Specifications:
KARL STORZ HD and FULL HD Monitors
19"
26"
27"
Desktop with pedestal
optional
optional
optional
Product no.
9619 NB
9826 NB
9627 NB/NB-2
Brightness
200 cd/m2 (typ)
500 cd/m2 (typ)
240 cd/m2 (typ)
Max. viewing angle
178 vertical
178 vertical
178 vertical
Pixel distance
0.29 mm
0.3 mm
0.3 mm
Reaction time
5 ms
8 ms
12 ms
Contrast ratio
700:1
1400:1
3000:1
Mount
100 mm VESA
100 mm VESA
100 mm VESA
Weight
7.6 kg
7.7 kg
9.8 kg
Rated power
28 W
72 W
45 W
Operating conditions
040C
535C
535C
Storage
-2060C
-2060C
-2060C
Rel. humidity
max. 85%
max. 85%
max. 85%
469.5 x 416 x 75.5 mm
643 x 396 x 87 mm
776 x 443 x 114 mm
Power supply
100240 VAC
100240 VAC
85265 VAC
Certified to
EN 60601-1,
protection class IPX0
EN 60601-1, UL 60601-1,
MDD93/42/EEC,
EN 60601-1, UL 60601-1,
MDD93/42/EEC,
36
Data Management and Documentation

KARL STORZ AIDA Exceptional documentation
The name AIDA stands for the comprehensive implementation

of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.
WD 200-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
WD 250-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
including SMARTSCREEN (touch|screen),
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
*XX Please indicate the relevant country code

(DE, EN, ES, FR, IT, PT, RU) when placing your order.
Workflow-oriented use
Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
All important patient information is just a click away.
Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.
Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.
Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.
Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.
Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
37
38
Accessories for Video Documentation
495 NL
Fiber Optic Light Cable,

with straight connector, diameter 3.5 mm,
length 180 cm
495 NA
Same, length 230 cm
Cold Light Fountain XENON 300 SCB
20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 125 VAC/220 240 VAC, 50/60 Hz
including:
Mains Cord
SCB Connecting Cord, length 100 cm
20133027
Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028
XENON Spare Lamp, only,
300 watt, 15 volt
Cold Light Fountain XENON NOVA 300
20 134001
20133028
Cold Light Fountain XENON NOVA 300,

power supply:
100125 VCA/220240 VAC, 50/60 Hz
including:
Mains Cord
XENON Spare Lamp, only,
300 watt, 15 volt
39
Equipment Cart
UG 220
Equipment Cart
wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 540
Monitor Swifel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx
UG 220
UG 540
40
Recommended Accessories for Equipment Cart
UG 310
Isolation Transformer,
200 V 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
UG 410
Earth Leakage Monitor,

200 V 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310
UG 510
Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or right,
turning radius approx. 320, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
UG 310
UG 410
UG 510
Notes:
41
42
Notes:
with the compliments of

KARL STORZENDOSKOPE

Arthroscopy of The Temporomandibular Joint - Storz

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ARTHROSCOPY OF THE

Arthroscopy of the Temporomandibular Joint

GmbH at the address shown above.

Any legal claims or claims for damages are excluded.

Arthroscopy of the Temporomandibular Joint

2.0 Our Protocol for the Treatment

3.0 Diagnostic Arthroscopy of the Temporomandibular Joint . . . . . 8

5.0 Arthroscopic Training in an Animal Model . . . . . . . . . . . . . . . . . . 17

7.0 Concluding Remarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Arthroscopy of the Temporomandibular Joint

As in all degenerative muscle, bone and joint diseases,

The following components may also play a role:

At our institution in Greifswald, we have solved the

Arthroscopy of the Temporomandibular Joint

2.0 Our Protocol for the Treatment of TMJ Disc Displacements

Next: 3 months of conservative therapy (physical

Conservative treatment is continued for up to one

Most chronic, non-reducing disc displacements begin

Permanent correction to a centric jaw position

If the TMJ disorder has not improved or is worse by

If the TMJ is not permanently corrected to a centric

Arthroscopy of the Temporomandibular Joint

3.0 Diagnostic Arthroscopy of the Temporomandibular Joint

3.2 Preoperative Preparations, Draping,|

Arthroscopy is contraindicated in patients with acute

Skin marking pen

Arthroscopy of the Temporomandibular Joint

3.3 Arthroscopic Approach to the

1 Locate and mark the center of the tragus.

tragus and the lateral canthus.

10 mm from the center of the tragus, and mark

Before inserting the trocars, we palpate the TMJ region

Puncturing the Joint:

Next open the inflow stopcock on the arthroscope

Arthroscopy of the Temporomandibular Joint

Another technique for puncturing the upper joint space

3.4 Instrument Use, Description of Findings and Documentation

plane. Because working with a 30 scope is somewhat

After introducing the arthroscope, the surgeon establishes orientation

Arthroscopy of the Temporomandibular Joint

If a red-out occurs during arthroscopy (Fig. 5), this

classifying disc displacement.

the landmarks simultaneously in the same

Two useful landmarks are the usually well-defined

the problem of projecting a measurement scale into

Arthroscopy of the Temporomandibular Joint

Classification of disc and retrodiscal changes by

Arthroscopic view of a stage II disc

View of the articular tubercle and underlying

View of the hyperplastic retrodiscal tissue (c).

Arthroscopy of the Temporomandibular Joint

Stage III anterior disc displacement (Fig. 8): The disc

Arthroscopic appearance of the retrodiscal tissue and medial

Schematic representation of the stages of anterior disc displacement.

Arthroscopy of the Temporomandibular Joint

4.0 Minimally Invasive Arthroscopic Treatment of Disk|

The rationale of this procedure is to shorten and tighten

Arthroscopy of the Temporomandibular Joint