(81) Level III TMJ Arthroscopy: A Simple and Reproducible Technique for Disc Suture With a Semi-Rigid Anchorage Under the Cartilage of the External Auditory Canal

Abstract: Temporomandibular joint (TMJ) disorders, particularly those involving disc displacement, can be treated through arthroscopic procedures. Traditional techniques for arthroscopic disc repositioning and suturing, although effective, are often complex and require a steep learning curve.
This study proposes a simplified arthroscopic technique for disc suturing, making it more reproducible.
Fourteen patients (12 female and 2 male), with a mean age of 22 years, who complained of TMJ pain, limited mouth opening, and had anteriorly displaced discs without reduction during mouth opening diagnosed by clinical examination and magnetic resonance imaging, were selected.
The simplified disc suturing technique was performed under general anesthesia using a 2.3 mm scope angled at 30 degrees. After performing diagnostic arthroscopy (arthroscopy level I) and visualizing the disc displacement, triangulation was performed through a second portal in the superior space (anterior recess), enabling capsulotomy and myotomy of the lateral pterygoid muscle to be performed using knife-type instruments. Then, using a non-perforating trocar inserted into this second portal, it is directed to the posterior recess (Figure 1), performing disc repositioning through an inferoposterior movement and maintained in this position. To perform the suture, a 14-gauge catheter with a 3.0 PDS (absorbable) thread positioned inside is inserted into the skin equidistant from the second portal and the first portal (arthroscope) up to the upper space of the TMJ, where the tip of the catheter with the thread can be seen through direct vision from the arthroscope. At this point, with the disc repositioned, the catheter is inserted from the direct view into the junction between the disc and the retrodiscal tissue, completely transfixing it laterally until it exits in the medial region. Then, a 3rd portal is introduced into the upper compartment (posterior recess) through a puncture made in the anterior wall of the external auditory canal, and with the aid of forceps, the thread in the medial region is removed to the outside. At this point, this 3rd portal can be removed. With caution, and under direct vision from the arthroscope, the catheter is slowly removed from inside the disc until it exits completely in the lateral region. Without the need for a fourth portal, using this same catheter with the thread already passed, it is directed to exit in the access region on the anterior wall of the external auditory canal (entry site of the 3rd portal) and the thread is removed from the catheter (Figure 2). Finally, with both ends of the thread in the access region of the anterior wall of the external auditory canal, the anchoring (suture) is performed in the cartilage of the external auditory canal.
The technique demonstrated a reduction in operative time due to the lack of need for a fourth working portal, making the procedure simpler and faster. There was successful repositioning and stabilization of the TMJ disc, as demonstrated by arthroscopic imaging (Figure 3) and post-surgical magnetic resonance imaging. Patients reported improvement in TMJ pain and increased mouth opening during our postoperative follow-up.
Therefore, this technique makes arthroscopic disc suturing simpler, more reproducible and with reduced operating time, while maintaining the effectiveness already described in other techniques.

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Figure 1: disc displacement without reduction before discopexy and non-perforating trocar in the posterior recessFigure 2: use of the catheter itself with the thread for exit through the external auditory canal approach Figure 3: disc in normal position after discopexy