J Maxillofac Oral Surg 8(4):371
371
TECHNICAL NOTE
An effective intra-operative method to control bleeding from vessels medial to the temporomandibular joint
Sanjeev Kumar1 · Vishal Bansal 2 · Rajat Agarwal3 1
Professor & HOD Associate Professor 3 Senior Lecturer 2
Dept. of Oral and Maxillofacial Surgery, Subharti Dental College, Meerut
Received: 24 July 2008 / Accepted: 23 November 2009 © Association of Oral and Maxillofacial Surgeons of India 2009
Abstract The control of hemorrhage from the medial aspect of the TMJ can be troublesome and time-cosuming during ankylosis surgery. There could be a number of vessels which could lead to this inadvertent though sometimes unavoidable complication. We have found that simple compression against bone can be useful in controlling hemorrhage from this difficult to approach site. This short paper describes the technique which we follow in our unit for such situations. Keywords TMJ surgery · Bleeding · Maxillary artery Aggressive resection of the condyle and/ or coronoid in cases of ankylosis is often complicated by severe hemorrhage from vessels which lie in close proximity to the medial aspect of the neck of the condyle. Any of the several vessels in the pterygoid fossa may be the cause of excessive bleeding. These include the maxillary artery and its branches namely, middle meningeal artery, mandibular artery and deep temporal artery [1,2]. The pterygoid venous plexus is also a frequent source of troublesome bleeding in TMJ surgery. Suggested management to control hemorrhage has included uni and bipolar electrocautery, laser ablation, local anesthetics with vasoconstrictors, direct pressure, embolization, and ligation [3]. The briskness of the hemorrhage, retraction of the bleeding vessel and the limited access often preclude the possibility of “catching” or ligating the bleeding vessel under vision. Firm packing of the pterygoid fossa with oxidized cellulose and dry ribbon gauze is the usual method of controlling such bleeding [1]. Often the pack has to be repeated, which adds significantly to the operative time. At times, when bleeding is tedious a BIPP/BPC ribbon pack is left in
situ for 3 days, which is removed carefully in installments over the next few days. This may necessitate extended hospitalization of the patient. In rare cases, external carotid artery may need to be ligated. Iatrogenic injury to both the middle meningeal and superficial temporal arteries during TMJ surgery has also been controlled by embolization with a gelatin-based hemostatic agent [3]. In our department, a simple technique of controlling hemorrhage by digital compression is being utilized which has shown to significantly control intra-operative bleeding from vessels medial to the condyle. Technique Firm pressure with the fore-finger applied intra-orally and directed posterolaterally in the region of the maxillary tuberosity immediately controls bleeding from vessels medial to the TMJ. This is so because the muscle bed which contains the bleeding vessel is compressed effectively against bone i.e. the pterygoid plates or the ramus of the mandible. This pressure must be maintained as long as necessary. We have applied this
Address for correspondence: Sanjeev Kumar B-10, Staff Quarters, Subhartipuram NH-58 Delhi-Haridwar Bypass Road Meerut-58, India Ph: 91-121-2439043,52 Fax: 91-121-2439067 E-mail:
[email protected]
technique to identify the source of the bleeding and ligate or cauterize the offending vessel under vision. As far as we are aware, this technique of controlling intra-operative bleeding from vessels medial to the condyle during TMJ surgery has not been described in the literature before.
References 1. Norman JEdeB, Bramley P editors. A textbook and colour atlas of the temporomandibular joint. London: Wolfe Medical Publications Ltd.: 1990:p. 169 2. Talebzadeh N, Rosenstein TP, Pogrel M (1999) Anatomy of structures medial to the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88(6): 674–678 3. Cillo JE Jr , Sinn D, Truelson J (2005) Management of Middle Meningeal and Superficial Temporal Artery Hemorrhage From Total Temporomandibular Joint Replacement Surgery With a Gelatin-Based Hemostatic Agent. J Craniofac Surg 16(2): 309–312
Source of Support: Nil, Conflict of interest: None declared.
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