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Procedures. Intermediate Format Temporomandibular Joint Arthroscopy. Objectives. Assess the related terminology and pathophysiology of the TMJ. Analyze the diagnostic interventions for a patient undergoing a _______________.

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procedures

Procedures

Intermediate Format

Temporomandibular Joint Arthroscopy

objectives
Objectives
  • Assess the related terminology and pathophysiology of the TMJ.
  • Analyze the diagnostic interventions for a patient undergoing a _______________.
  • Plan the intraoperative course for a patient undergoing_____________.
  • Assemble supplies, equipment, and instrumentation needed for the procedure.
objectives3
Objectives
  • Choose the appropriate patient position
  • Identify the incision used for the procedure
  • Analyze the procedural steps for TMJ Arthroscopy.
  • Describe the care of the specimen
terms and definitions
Terms and Definitions
  • Bruxism
  • Malocclusion
definition purpose of procedure

Definition/Purpose of Procedure

Temporomandibular Joint (TMJ) Disorder occurs when the muscles used in chewing and the joints of the jaw fail to work in combination with each other.

pathophysiology

Pathophysiology

Causes:

Bruxism, Malocclusion, Arthritis,

Trauma

pathophysiology8

Pathophysiology

Signs & Symptoms

Pain, clicking, limited range-of-motion, spasms, asymmetry

diagnosis

Diagnosis

Linear CT and MRI

treatment
Treatment
  • 5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery
  • Antiinflammatories, soft diet, hot compresses, muscle relaxants
  • >2 weeks: intraoral occlusion splints, med tx
  • Recurrent or chronic: permanent dental correction
surgical intervention special considerations
Surgical Intervention:Special Considerations
  • Patient Factors
    • Outpatient
    • H& P, Blood chemistries, CBC, PT, PTT, U/A, serum HCG, Chest x-ray or ECG as appropriate
  • Room Set-up
    • X-rays in room
surgical intervention positioning
Surgical Intervention: Positioning
  • Position during procedure
    • Supine w/head donut pillow, tuck arms to side
  • Supplies and equipment
    • Arm sleds, headring pillow
  • Special considerations: high risk areas
    • Elbows—ulnar nerves
  • Prep
    • Shave preauricular area
    • Cotton to ears to prevent pooling of povidone-iodine & caution w/eyes; entire facial area prepped from hairline, down to shoulder, and laterally to include mouth and chin
surgical intervention special considerations incision
Surgical Intervention: Special Considerations/Incision
  • Special considerations
    • Nasal intubation
    • Prophylactic antibiotics & steriods
  • State/Describe incision
    • Small stab incision w/# 11 before trocar is introduced at superior joint space
surgical intervention supplies
Surgical Intervention: Supplies
  • General: basic pack drape and split head sheet, gowns & gloves, towels, basin set, prep set, sterile adhesive wound drape, irrigation pouch, skin marker, raytex,
  • Specific
    • Suture & Blades (# 11)
    • Medications on field (name & purpose)
    • Catheters & Drains: n/a
    • Drapes: head turban for initial drape; pad pt forehead with a folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)
surgical intervention supplies cont d
Surgical Intervention: Supplies cont’d
  • 2 60 mL syringes
  • 4 10 mL syringes
  • 1 1-mL syringe
  • Needles: 18 g, 21 g, 25 g
  • Skin stapler
  • Eye pads
  • Sterile water and saline
  • 1000 mL Lactated Ringers for irrigation
  • 30 in extension tubing
  • Stopcock
surgical intervention instruments
Surgical Intervention: Instruments
  • General: suction, Lactated Ringer’s IV bag for irrigation, marking pen
  • Specific
    • TMJ instrument set
      • 0 degree arthroscope
      • 30-degree arthroscope
      • 70-degree arthroscope
      • Cannulas
      • Sharp & dull obturators
    • Light cord, camera & cord, small joint rotary shaver
surgical intervention equipment
Surgical Intervention: Equipment
  • General: suction system
  • Specific
    • Monitor/light source/camera tower, shaver control unit, IV pole for irrigant
    • Fluid infusion system
    • Bipolar ESU
    • Holmium laser
surgical intervention procedure steps
Surgical Intervention: Procedure Steps
  • Irrigation solution is injected into the joint space to distend the capsule
    • LR solution is preloaded in syringe w/needle attached.
  • After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures.
    • #11 blade with # 7 handle will be ready
    • Trocar/cannula is preassembled. Expect trocor to be returned. Be prepared to assist with connections of video/light cord connections.
surgical intervention procedure steps19
Surgical Intervention: Procedure Steps
  • Irrigation is infused into the joint
    • LR solution is connected to the cannua via extension tubing
  • Joint is examined
    • Prepare to operate remote control for still photos
  • If functional surgery is needed, a second stab wound is made
    • Pass skin knife. Prepare additional equipment (probe, shaver, grasper)
  • Final visual inspection is performed
    • Additional photos may be taken
surgical intervention procedure steps20
Surgical Intervention: Procedure Steps
  • Cannuale are removed and excess fluid removed
    • Prepare for closure; count
  • Wound is closed and dressing placed
    • Pass suture; prepare dressings, reorganize equipment & supplies if procedure is bilateral
  • Steps may be repeated contralaterally
    • Repeat steps
counts
Counts
  • Initial: sponges and sharps
  • First closing
  • Final closing
    • Sponges
    • Sharps
specimen care
Specimen & Care
  • Identified as n/a or as specified (eg chondromalacia)
  • Handled: routine, etc.
postop considerations
Postop Considerations
  • Immediate
    • ROM of jaw limited
    • Suction and Emergency airway supplies readily available; Elevate HOB 30 degrees
    • Ice for pain and swelling
    • Liquid or soft diet for several days
  • Prognosis: good—may recur if behaviors not resolved; PT may begin in 24-48 hrs post-op.
  • Complications: hemorrhage, infection, recurrence
    • Joint damage, destruction of middle ear ossicles, perforation into middle cranial fossa, injury to auriculotemporal nerve
resources
Resources
  • www.healthscout.com
  • STST pp. 646-647, Procedure 18-7
  • www.dentaljournal.com/article 6
  • Rodau; Baker-Gill, Levin; “Arthroscopic Temporomandibular Joint Surgery”, AORNJournal Nov 1993, 58: 5.