Amidst the many new patient consults I see in my practice, there are a number of situations where surgical care is necessary to repair compromised TMJ anatomy and address persistent inflammation and arthritic changes. As with all orthopedic problems there are times when non-surgical therapy falls short. When dealing specifically with temporomandibular problems, symptoms of pain, limited jaw motion, joint noises, and bite changes often drive a discussion of the surgical options available. Pain, as suspected, influences a great number of these decisions and continues to be the primary reason that surgical options are explored.
For many patients non-surgical care will eradicate pain, improve motion and facilitate the return to normal jaw function, despite the altered anatomic state noted on TMJ MRI scans. I would venture to say that upwards of 85% to 90% of these patients recover, and are discharged after several months of care. It is extremely satisfying to see, when patients return over the years for oral appliance work or replacement, how nature induces adaptive changes that are stable from a joint and occlusal perspective
The other 15% of these patients will suffer with pain, over-consume pain medications, experience eating restrictions, weight loss, bite changes and limited jaw opening that prevents them from seeking dental care. It all contributes to the need to explore surgical remedies.
The challenge then lies in determining which of a number of surgical options should be chosen, the nature of post-surgical care, and most importantly, how to address the factors that may have caused the problem in the first place.
TMJ Surgical Options
The most common surgical options include arthrocentesis, arthroscopic surgery, and open joint procedures (arthroplasty) designed to re-secure the disc (if possible) in its normal location and address bone compromises.
The choice of an arthrocentesis or arthroscopic procedure leads to therapy that does not restore normal joint anatomy. Rather, these procedures (with strong advocates on each side) are designed to free-up the displaced disc so it can be pushed overtime to what I call “a better bad place.” In addition, these procedures have the intent of breaking up adhesions, washing out inflammatory mediators and debris, and in the case of arthroscopic surgery, to improve bony anatomy and obtain biopsy specimens where indicated.
The key to the success of arthrocentesis and arthroscopic procedures is the restoration of motion and the reduction or cessation of pain. If this occurs, joint adaptation is markedly facilitated as long as post surgical care is put into place. Post-operative care will include home exercises to restore jaw motion and muscle co- ordination, formal physiotherapy, oral appliance use, medications and dietary caution as healing occurs.
The choice of an open joint procedure (arthroplasty) has the intent of restoring joint anatomy by re-securing the articular disc in a normal position along with re-contouring the underlying bony anatomy revealed on CT and MRI scans. There are a number of techniques used to re-secure the articular disc and some surgeons choose to re-contour the articular eminences facilitate joint translation. The goals remain the same; improving motion, getting rid of inflammation and at times improving joint architecture. Post-surgical care again is critical for success to be realized.
As with all joints in the body, there will always be some disagreement as to when surgical care is necessary and, if chosen, the best technique to perform. Though biases remain, we should not exclude surgical intervention. It is a critical component of the care that I recommend for patients who have profound joint compromise and have not been respondent to non-surgical intervention.
Our goal must be to continue to better understand why these problems occur, how to address risk factors when possible, and how to engage patients in the care process. Despite the varied directions of surgical intervention that my patients have chosen with guidance, the vast majority over the last 35 years fortunately have had positive outcomes with restoration of normal and pain free-jaw function.
I welcome your thoughts.