Technical Note
Internal Maxillary Artery Preoperative Embolization Using n-Butyl Cyanoacrylate and
Pushable Coils for Temporomandibular Joint Ankylosis Surgery
Yazan J. Alderazi1,2, Darshan Shastri1, John Wessel3, Melvin Mathew1, Tareq Kass-Hout1,4, Shahid R. Aziz3, Charles
J. Prestigiacomo1, Chirag D. Gandhi1
- BACKGROUND: Temporomandibular joint (TMJ) anky-
losis causes disability through impaired digestion, masti-
cation, speech, and appearance. Surgical treatment
increases range of motion with resultant functional
improvement. However, substantial perioperative blood loss
can occur (up to 3 L) if the internal maxillary artery (IMAX) is
injured as it traverses the ankylotic mass. Achieving hemo-
stasis is difficult because of limited proximal IMAX access
and poor visualization. Our aim is to investigate the technical
feasibility and preliminary safety of preoperative IMAX
embolization in patients undergoing TMJ ankylosis surgery.
- METHODS: Case series using chart reviews of 2 patients
who underwent preoperative embolization before TMJ
ankylosis surgery.
- RESULTS: Both patients were women (28 and 51 years old)
who had severely restricted mouth opening. Embolization
was performed using general anesthesia with nasal intuba-
tion on the same day of TMJ surgery. Both patients underwent
bilateral IMAX embolization using pushable coils (Vortex,
Boston Scientific) of distal IMAX followed by n-butyl-
cyanoacrylate (Trufill, Cordis) embolization from coil mass up
to proximal IMAX. There were no complications from the
embolization procedures. Both patients had normal neuro-
logic examination results. TMJ surgery occurred with mini-
mal operative blood loss (300 mL for each surgery).
Maximum postoperative mouth opening was 35 mm and
34 mm, respectively. One patient had a postoperative TMJ
wound infection that was managed with antibiotics.
Key words
- Embolization
- Internal maxillary artery
- Preoperative embolization
- Temporomandibular joint ankylosis
- Temporomandibular joint surgery
Abbreviations and Acronyms
IMAX: Internal maxillary artery
nBCA: n-Butyl-cyanoacrylate
TMJ: Temporomandibular joint
From the 1Division of Endovascular Neurosurgery, Department of Neurological Surgery,
Rutgers University, New Jersey Medical School, Newark, New Jersey; 2Division of
254 www.SCIENCEDIRECT.com
- CONCLUSIONS: Preoperative IMAX embolization before
TMJ ankylosis surgery is technically feasible with
encouraging preliminary safety. There were no complica-
tions from the embolization procedures and surgeries
occurred with low volumes of blood loss.
INTRODUCTION
T emporomandibular joint (TMJ) ankylosis causes disability
through impaired digestion, mastication, speech, and
appearance.1,2 Surgical treatment increases range of
1,3
motion. This allows improvement in chewing, swallowing, and
pronunciation.1 Current literature suggests that postoperative
complications are uncommon, with rates of 1.7%e10.3%.1,3
However, perioperative blood loss can be substantial, with vol-
umes as high as 3 L of blood loss after damage to the internal
maxillary artery (IMAX).4-6 Most often, injury to this artery occurs
during total TMJ replacement.7 In addition, the anatomy can be
challenging in the setting of severe ankylosis that impairs
visualization and in cases where the internal maxillary artery
traverses the ankylotic mass.6 After damage to the vessel, it is
difficult to control the hemorrhage due to limited access and
poor visualization of the IMAX.5 There is currently no
high-quality evidence to support or refute the practice of IMAX
embolization before TMJ surgery.6
Our aim is to investigate the technical feasibility of using a
combination of pushable coils and n-butyl-cyanoacrylate (nBCA)
for preoperative IMAX embolization before TMJ surgery; and to
describe the preliminary safety.
Neurointerventional Surgery, Department of Neurology, Texas Tech University Health
Sciences Center School of Medicine, Lubbock, Texas; 3Department of Oral and Maxillofacial
Surgery, Rutgers School of Dental Medicine, Newark, New Jersey; and 4Department of
Surgery, Rochester Regional Health System, Rochester, New York, USA
To whom correspondence should be addressed: Yazan J. Alderazi, M.B., B.Ch.
[E-mail: yazanalderazi@yahoo.com]
Citation: World Neurosurg. (2017) 101:254-258.
http://dx.doi.org/10.1016/j.wneu.2017.01.086
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2017 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.086

Figure 1. A 28-year-old woman with preoperative
bilateral internal maxillary artery embolization for
temporomandibular joint arthroplasty. Preembolization
angiograms, lateral views, of the (A) left and (B) right
internal maxillary arteries. Postembolization
METHODS
This is a case series of patients undergoing preoperative IMAX
embolization before surgery for TMJ ankylosis. The patients
were admitted to the hospital between January 1, 2013, and
June 30, 2014. We reviewed the charts and imaging of each
patients hospital record. The institutional review board gran-
ted exemption approval for the study and for the request for a
waiver of informed consent for our research.
RESULTS
This case series consists of 2 patients.
Patient 1
A 28-year-old woman with a significant medical history of rheu-
matoid arthritis was seen for the treatment of bilateral TMJ bony
ankylosis. She had previously undergone 7 treatments for TMJ
ankylosis, including most recently a bilateral gap arthroplasty
with Derma Matrix interpositional graft (Synthesis CMF, West
Chester, Pennsylvania, USA) for severe degenerative joint
disease. Clinical examination demonstrated a mouth opening of
less than 15 mm with persistent pain. A decision was made to
proceed with total joint replacement of the right and left TMJs
with preoperative bilateral IMAX embolization to decrease the
risk of hemorrhagic complications during surgery.
The procedure was performed using general anesthesia after the
patient had been electively intubated nasally in the operating
room. The patient was transferred to the neurointerventional suite
for bilateral IMAX embolization. Right femoral access was used. A
6-French Envoy MPD (Codman and Shurtleff, Inc., Raynham,
Massachusetts, USA) was advanced into the aortic arch and
WORLD NEUROSURGERY 101: 254-258, MAY 2017
TECHNICAL NOTE
angiograms of the (C) left and (D) right internal maxillary
arteries demonstrating no residual flow between the
push-coils distally (arrow) and the n-butyl-cyanoacrylate
(double arrows) casts proximally.
navigated to the left internal carotid artery. Control angiography to
assess for potential dangerous anastomosis was performed. The
catheter was then repositioned into the left external carotid artery.
There the IMAX and occipital artery were visualized, but the su-
perficial temporal artery was not visualized, most likely because of
prior ligation during surgery. A Prowler Select Plus microcatheter
(Cordis) was advanced over a Transend-14 floppy microwire
(Stryker, Kalamazoo, Michigan, USA) using a roadmap technique
into the distal internal maxillary artery. A 4  3.7-mm pushable
Vortex Coil was then deployed in the distal IMAX. Next, nBCA
(Trufill; 50% concentration, 1 mL) was slowly injected into the
IMAX. The target of embolization was the segment of the IMAX
medial and deep to the ramus of the mandible. The microcatheter
was positioned to achieve embolization from the coil mass distally
to the proximal IMAX distal to the origin of the superficial temporal
artery. The distal coil mass was used to prevent nBCA from distal
embolization and proximal reflux safety was ensured by posi-
tioning of the microcatheter. nBCA was not allowed to reflux onto
the microcatheter. Control angiography of the external carotid
artery demonstrated complete occlusion of the IMAX from the
nBCA cast proximally to the coil distally. There was distal recon-
stitution of the internal maxillary artery through the facial artery and
ethmoidal branches. Control angiography of the left internal
carotid artery showed no evidence of thromboembolic complica-
tions. The same procedure with 0.8 mL nBCA (50% concentration)
was used for embolization of the right IMAX with similar results
(Figure 1). The level of anesthesia was reduced, and the results of a
neurologic examination while the patient remained intubated were
normal. The procedure took 1.5 hours and was completed without
any complications.
The patient was then transferred to the operating room for
bilateral TMJ arthroplasty and coronoidectomies followed by total
www.WORLDNEUROSURGERY.org 255
TECHNICAL NOTE
Figure 2. A 51-year-old woman with bilateral internal
maxillary artery embolization before
temporomandibular joint replacement. Pre-
embolization angiograms, lateral views, of the (A) left
and (B) right internal maxillary arteries (dashed arrows).
joint replacement. The estimated blood loss during surgery was
300 mL. Maximum mouth opening at the end of surgery before
extubation was 35 mm. Postoperative complications included
pain and emesis, which were effectively controlled with medi-
cation. The patient was discharged home neurologically intact;
however, she returned 10 days later with pain and swelling at the
left incision site. Computed tomographic scans revealed a com-
plex abscess around the TMJ arthroplasty. The patient under-
went incision and drainage of the left submandibular abscess
with minimal blood loss.
Patient 2
A 51-year-old woman was seen with progressive trismus caused
by bilateral TMJ ankylosis. She was unable to open her mouth.
Initial computed tomographic scans showed bilateral TMJ anky-
losis with joint space narrowing, subchondral sclerosis, and
articular bony erosion. A decision was made on a 2-stage surgery
for reconstruction of the TMJ joint. This included a bilateral TMJ
gap arthroplasty and coronoidectomies with insertions of a
256 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.086
Postembolization angiograms of the (C) left and (D)
right internal maxillary arteries demonstrating no
residual flow between the push coils distally (arrow)
and the n-butyl-cyanoacrylate casts proximally (double
arrows).
bilateral TMJ Silastic splitter followed by a second procedure to
remove the Silastic splitters and to insert a custom alloplastic
prosthesis (TMJ Concepts, Ventura, California, USA). Bilateral
IMAX embolization was completed before the first surgery.
The procedure was performed using general anesthesia after the
patient was electively intubated nasally in the operating room.
The patient was transferred to the neurointerventional suite for
bilateral IMAX embolization. Through a 6-French short right
femoral artery access sheath, a 6-French Envoy MPD (Codman
and Shurtleff) was advanced into the aortic arch and navigated to
the right external carotid artery after control angiography of the
right internal carotid artery. There was a focal stenosis of the
external carotid artery just distal to the origin of the facial artery.
A Prowler select plus microcatheter (Cordis) was advanced over
a Synchro 2 soft microwire (Stryker) using a roadmap technique
into the distal IMAX. Intravenous heparin was given to maintain
activated coagulation time at 200e300 seconds. The microwire
was removed followed by sequential placement of 2 Vortex coils
measuring 6  6.7 mm and 5  5.5 mm into the distal IMAX.

Next, 0.05 mL nBCA (50% concentration) was injected under
fluoroscopy to achieve embolization from the coil mass distally to
the proximal IMAX distal to the origin of the superficial temporal
artery. Control angiography of the external carotid artery after
embolization demonstrated complete occlusion of the IMAX from
the nBCA cast proximally to the coils distally (Figure 2). Using the
same technique, the right IMAX was embolized using two Vortex
coils measuring 6  6.7 mm and 4  3.7 mm, followed by 0.7 mL
nBCA glue (50% concentration). The procedure was completed in
1.5 hours and without thromboembolic complication (Figure 2).
The patient then underwent the first stage of TMJ replacement.
Intraoperative blood loss was 300 mL. A maximal mouth opening
of 46 mm was checked during surgery. Radiography of the
mandible showed embolization coils overlying the condylar re-
gions of each mandible and embolization nBCA cast, overlying
the subchondral region of the left mandible as well. The results of
a neurologic examination were normal after extubation. There
were no postoperative complications. The patient later returned
for the second stage of TMJ replacement, in which the intra-
operative blood loss was 250 mL. The procedure was completed
without any intraoperative or postoperative hemorrhagic com-
plications, and the patient was discharged home. A follow-up
appointment 4 months later showed a maximum mouth open-
ing of 34 mm.
DISCUSSION
Technical Discussion
The present case series demonstrates the technical feasibility
and preliminary safety of preoperative embolization of the IMAX
before TMJ ankylosis surgery to reduce hemorrhagic complica-
tions. There were no complications from the embolization.
Furthermore, the results suggest that preoperative embolization
may help to reduce intraoperative blood loss and postoperative
hemorrhagic complications. The subsequent TMJ surgeries
occurred with minimal blood loss (300 mL). Damage to the IMAX
during TMJ total joint replacement is uncommon, it but can cause
significant intraoperative blood loss.6,8 Selective IMAX emboli-
zation has been described to control iatrogenic injury to the artery
during these procedures.4 There is limited literature regarding
preoperative embolization of IMAX for TMJ ankylosis
surgerymainly by deploying detachable platinum coils in the
segment that passes through the ankylosis.7 The cases in our
series involved bilateral embolization of the internal maxillary
artery, distally by Vortex pushable coils and proximally with
nBCA. The target of embolization was the segment of the
IMAX medial and deep to the ramus of the mandible. This
segment was chosen because it is the most difficult site for
the surgeon to achieve proximal control. The pushable coils
were used to define the distal end of the segment to be
embolized, as distal embolization is not necessary in TMJ
surgery, and to protect from inadvertent embolization of the
ethmoidal arteries and collaterals. nBCA was used to create a
cast occluding the IMAX deep to the maxillary ramus until the
proximal safety zone. The purpose was to achieve controlled
occlusion of a defined segment, with no residual blood flow in
the embolized segments. The use of bilateral IMAX
embolization in our series is supported by the previous report
of failure of unilateral embolization to prevent bleeding in this
condition.7 Bilateral embolization of the distal IMAX is an
established and safe technique in the treatment of epistaxis
WORLD NEUROSURGERY 101: 254-258, MAY 2017
TECHNICAL NOTE
because of rich anastomosis of the preserved external carotid
artery branches supplying the extracranial structures. Of note,
as the technique described in our case series uses liquid
embolic agents, careful knowledge and assessment of
extracranial-to-intracranial anastomosis is prudent. Baseline an-
giograms of the internal and external carotid arteries are
mandatory before embolization to assess for potential dangerous
anastomoses. These potential dangers include the various mid-
dle meningeal artery and inferolateral trunk variants with anas-
tomosis with the retina and internal carotid artery respectively.
For this reason, 50% concentration of nBCA was used because it
is less likely to flow distally. In addition, adequate positioning of
the microcatheter in a non-wedged position and gentle injection
were used to avoid opening of an anastomosis that may have
been initially invisible angiographically. The technical advantages
of the present technique are a rapid and complete occlusion of
the desired segment with the use of a few relatively inexpensive
coils and 1 vial of nBCA. The technical limitations are lack of
complete control of nBCA liquid embolic agent, potential embo-
lization through unopacified anastomosis, and the inability to
reposition either the coils or nBCA.
Safety of Internal Maxillary Artery Embolization
Traditionally, preoperative embolization has been used in the
treatment of hypervascular tumors, such as juvenile nasophar-
yngioma, meningioma, paraganglioma, and in the treatment of
epistaxis.9-11 By occluding the feeding arteries, blood flow to the
tumor is decreased, allowing for decreased intraoperative blood
loss and a more precise surgical resection.12 A retrospective
review of 100 patients with preoperative embolization for head,
neck, and spine tumors reported no mortality or major
complications associated with the procedure.13 In addition,
more than 72% of patients had an intraoperative blood loss of
less than 500 mL.
Epistaxis is a relatively common condition, controlled by
applying pressure or anterior nasal packing, and electrocautery,
yet some cases of recurrent idiopathic and traumatic forms of
epistaxis require surgical or endovascular intervention.14
Because of the complex anatomy and rich vascular supply of
the nasal cavity, multiple arteries are usually embolized,
almost always including bilateral IMAX branches.9 Successful
control of epistaxis through embolization of IMAX and other
external carotid artery branches is reported to be 93%e100%
for initial success, and 77%e94% when early rebleeding is
taken into consideration with an acceptable safety profile.15,16
It is important to note that embolization for TMJ surgery dif-
fers from epistaxis treatment in that it involves a more proximal
segment of the IMAX with preservation of nasal mucosa flow
via collateral circulation.
Limitations
In our series, there were several unavoidable inherent limitations
because of the retrospective design of the case series. The
treatment allocation was based on clinical judgment of treating
physicians and was therefore nonrandom, which represents se-
lection bias. Another major limitation is the absence of an un-
treated control group with which to compare the safety and
efficacy of preoperative IMAX embolization in this condition. This
series does not allow comparison with other potential emboli-
zation techniques. While bilateral distal IMAX embolization is safe
as in epistaxis treatment, there are fewer data regarding bilateral
www.WORLDNEUROSURGERY.org 257
TECHNICAL NOTE

proximal IMAX embolization, as it is rarely performed for other
conditions. Finally, the small number of patients undergoing this
therapy limited our ability to conduct quantitative analysis and to
determine rare complications. Potential complications include
ischemia in the surgical field and inadvertent embolization of
other potentially eloquent territories through anastomosis or
reflux.
CONCLUSION
The present series demonstrates technical feasibility and pre-
liminary safety of this technique. However, further research with
a comparison group and quantitative analysis is necessary to
elucidate the risks and benefits of preoperative embolization and
which patient populations would benefit the most from this
intervention.
ACKNOWLEDGMENTS
Yazan J. Alderazi, Darshan Shastri, and Chirag D. Gandhi
conceived and designed the study. Yazan J. Alderazi, Darshan
Shastri, John Wessel, a Melvin Mathew acquired the data. Yazan
J. Alderazi, Darshan Shastri, and Tareq Kass-Hout analyzed and
interpreted the data. Yazan J. Alderazi and Darshan Shastri wrote
the manuscript. Charles J. Prestigiacomo, John Wessel, and
Chirag D. Gandhi provided critical revision and important intel-
lectual content. Charles J. Prestigiacomo, Shahid R. Aziz, and
Chirag D. Gandhi supervised the study.

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An institutional review board granted approval for the
study and for the request for waiver of informed consent
for our research.
Received 15 September 2016; accepted 20 January 2017
Citation: World Neurosurg. (2017) 101:254-258.
http://dx.doi.org/10.1016/j.wneu.2017.01.086
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2017 Elsevier Inc. All
rights reserved.

258 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.086