TMJ Surgery
What is the TMJ?
The temporomandibular joint, or TMJ, is a small joint located in front of the ear where the skull and lower jaw meet. This joint allows the lower jaw (mandible) to move and function, and is the most constantly used joint in the body. The TMJ is a "ball and socket" joint, and the round end, or "ball" portion, is called the condyle; the socket is called the articular fossa. Between the condyle and the fossa is a disc made of cartilage that acts as a cushion to absorb stress and allows the condyle to easily move when the mouth opens and closes.
At the back of the joint, the disc attaches to tissue that contains nerves and blood vessels and can be quite sensitive. Ligaments hold the disc and condyle in place, and muscles surrounding the TMJ also help stabilize the joint as well as move the lower jaw during chewing, speaking and other functions.
The teeth themselves are also important for proper TMJ function, because if they don't fit together properly, stresses can be generated that can displace the condyle and damage the disc, ligaments, and muscles. Trauma can also damage the TMJ and inhibit proper function.
When all of the elements of the TMJ are in harmony and working properly, the joint operates smoothly and without problems. However, TMJ disorders can develop if these elements are not functioning as they should, or if stresses, trauma, or other factors generate TMJ problems.
What are TMJ disorders?
TMJ disorders can be relatively minor, or they can be extremely painful and potentially debilitating. Emotional stress, with attendant habits such as grinding or clenching the teeth, can trigger TMJ symptoms as well as muscle spasms around the joint and jaws. Malpositioned jaws may also produce TMJ problems and, in some cases, arthritis may be the cause of TMJ disorders. Injury, such as a blow to the chin or jaw, can displace the condyle or disc, thus causing problems. In some cases of TMJ disorder, the disc is displaced, which interferes with its ability to properly interface between the "ball" and "socket." The sensitive layer of tissue behind the disc becomes the cushion, and the result is tenderness and pain in the joint.
In some cases, the disc may move so far forward that the mouth cannot be widely opened. This condition can cause degenerative joint disease, a form of arthritis involving the bones of the joint.
What are common symptoms of TMJ disorders?
Patients with TMJ disorders can display a variety of symptoms, and certain signs may indicate the potential for TMJ disorders to develop. The following are signs and symptoms that are possible in patients with TMJ problems:
- Painful clicks or pops in the joint when opening or closing the mouth
- A habit of tooth grinding or clenching
- Sore jaw muscles when awakening
- Difficulty in opening the mouth fully
- Frequent headaches or neckaches
- Pain in the TMJ area
- Locking of the jaw
Presence of some of these signs and symptoms could also indicate a specific type of disorder known as myofascial pain dysfunction syndrome, or MPD. This disorder is accompanied by muscle pain and tenderness, limitation in range of jaw motion, and local pain usually limited to one side of the face. Your oral and maxillofacial surgeon can diagnose this disorder when evaluating your need for TMJ treatment.
Evaluating your need for tmj treatment:
You should be prepared to complete a thorough medical history, including information about your lifestyle and the level of stress you experience on a daily basis. Your oral surgeon will physically examine your head and neck area, including the TMJ, and a variety of tests may be used to confirm or eliminate a diagnosis of a TMJ disorder. These tests may include:
- X-rays
- Magnetic Resonance Imaging (MRI) to produce images of soft tissue
- Computerized Tomography (CT scans) to identify bone problems
Your teeth will also be examined, and models or molds may be made of your teeth, so the surgeon can determine if your bite is contributing to your TMJ problem.
When discussing your medical history with your surgeon, make sure you give helpful details about the following areas:
- Origin of the problem
- Duration and character of any pain you are experiencing
- Joint noises (clicking, popping, cracking)
- Range of motion of the lower jaw
- Trauma to the head or neck area
- Stress level experienced at home or work
- Any related discomforts
- Previous or current treatments
What are the benefits of TMJ Therapy?
The TMJ is the most constantly used joint in the body, and if a TMJ disorder exists, it can make the simplest acts of eating, talking, or even yawning extremely painful. If you suspect a TMJ disorder, discuss your condition with your oral and maxillofacial surgeon. He or she can work with you to diagnose your specific problem and recommend a broad range of treatment options, including simple self-care programs to more complex surgical procedures, outlined below. Because many TMJ problems are related to lifestyle and habits, it is important that you work with your surgeon to determine the best option for you.
Treatment Options for TMJ Disorders
Self-Care:
In almost all cases, it is important to rest the jaw by keeping the teeth apart for periods of time and to practice good posture. It may be necessary to avoid hard foods that strain the jaw when chewing. Proper exercise of the jaw may also be helpful at appropriate times. Flexing exercises can help restore normal range of jaw motion in cases where jaw movement is restricted by a TMJ disorder. These exercises should consist of gentle opening/closing movements to avoid stressing the joint. Moist heat can also be used to help relax muscles, and in cases of joint injury, ice packs applied soon after the injury can help reduce swelling. Relaxation techniques may also be a part of your self-care program, along with any medication your surgeon may provide, including muscle relaxants or anti-inflammatory drugs.
Physical Therapy:
There are a variety of physical therapy techniques that can be used to treat certain types of TMJ disorders, and these may require referral to the appropriate specialist. These techniques include:
- Jaw exercises
- Posture training
- Electrical stimulation
- Ultrasound
- Biofeedback
Dental Treatment / Splint Therapy:
Your surgeon may recommend the construction of a nightguard device or occlusal splint to be worn for varying amounts of time, depending on the nature of your TMJ problem. There are many types of splints to help reposition the jaw, prevent clenching and grinding of the teeth, rest the jaws, and help relax jaw muscles. If the position of the jaws is incorrect, corrective jaw surgery to reposition the upper and/or lower jaw may be indicated to restore balance and be potentially helpful in resolving the disorder.
TMJ Surgical Options
It is important to understand that even if non-invasive procedures are ineffective in certain cases, surgery may not be the next step if the diagnosis indicates that surgical procedures will not help; for example, if your problem is muscular in origin rather than originating from within the joint itself. However, in cases where the diagnosis indicates a specific problem within the TMJ, joint surgery may be an appropriate treatment. Here are some treatments you may consider:
Arthroscopy:
An arthroscope is a miniature telescopic instrument, like that used for many years with knee joints, through which the contents of the jaw joint can be viewed. Using a special arthroscope small enough to enter the TMJ, the surgeon can visualize the joint and can perform minor surgical procedures such as treating cartilage damage. Arthroscopic surgery is performed in a hospital or ambulatory surgical centre under general anesthesia, using the same sterile and surgical conditions as for other types of joint surgery. With the patient asleep, the TMJ is injected with a local anesthetic and sterile solutions to flush out the joint. The TMJ is then carefully entered with the arthroscope. After the arthroscope has been placed, a small camera is connected to the instrument at one end and to digital equipment at the other end. The surgeon views the magnified anatomy of the joint on a television screen while the surgical field is under irrigation with sterile solutions. The surgeon can then perform needed treatment, such as removing scar tissue, inflammatory tissue, and broken cartilage that is interfering with joint function. In certain circumstances, radiofrequency coblation surgery is used.
Arthroplasty:
In some cases, arthroscopic surgery may be incapable of correcting a TMJ problem and other surgical procedures may be considered. For example, if a disc is displaced and cannot be moved back into proper position, then "open" surgery may be needed to expose the joint and allow more complex treatment procedures to be performed. Arthroplasty involves making an incision in front of the ear to expose the joint so the surgeon can repair a disc or ligament.
More complex TMJ surgery:
In the event of severe joint deterioration, like in certain cases of arthritis affecting the TMJ, more extensive surgical procedures are available to treat the problem. As with arthroplasty, an external incision is made to expose the joint, and then procedures such as re-contouring the bone of the joint, replacement of a disc, or rarely, artificial replacement of the entire joint can be performed.
What to Expect During TMJ Surgery
Anesthesia:
TMJ Surgery is performed under general anesthesia in a hospital or ambulatory surgical centre. Before surgery, you may be asked to have a physical exam to ensure that you are in good overall health, and required lab tests will be done prior to, or shortly after, admission to the hospital. Your anesthesiologist or anesthetist will discuss the general anesthetic procedures to be used and answer any questions you may have. It is very important that you adhere to any medication schedule and diet prescribed by your surgeon prior to surgery.
The Surgical Procedure:
As noted previously, TMJ surgery can range from minimally invasive arthroscopy to flush out a joint and make minor repairs, to complex joint surgery that repositions or replaces a disc, or even artificially replaces the entire joint. The surgical procedure may last from one to several hours.
Following TMJ Surgery:
Immediately following surgery, you will be moved to a recovery room until the general anesthetic has worn off. Your family is not be allowed in the recovery room, but they should be able to visit you shortly afterwards. An intravenous apparatus attached to your arm will provide required medications and nutrients until you are able to take sufficient nutrients orally.
Depending on the complexity of the surgery, the amount of swelling will vary. For arthroscopic procedures, there is little swelling, but even minimal swelling may cause the ears to ring and the joint and ear to ache. Also, your bite may be temporarily out of alignment. You may be required to wear an occlusal splint, and a soft diet should be adhered to for a few weeks. As a general rule, the more complex the surgical procedure, the longer the recovery time.
Follow-up care to TMJ Surgery:
After TMJ surgery, it is important that you avoid as many factors as possible that could contribute to a return of your TMJ disorder. Control of stress, avoidance of hard foods, protecting the jaw joints from injury, and adhering to the self-care program described earlier can help reduce the recurrence of TMJ issues. Your oral and maxillofacial surgeon will discuss ongoing treatment options such as occlusal splints, physical therapy and other techniques applicable to your individual case.
known risks and complications of tmj surgery:
As with any surgical procedure, certain side effects and complications are possible within TMJ surgery. You should understand these before you consent to surgery. Your surgeon will be happy to answer any questions you have about the following potential risks:
- Swelling and muscle stiffness is a normal reaction to any surgical procedure, and the amount varies by individual and procedure. Swelling will increase for approximately 24 hours after surgery, and typically remains unchanged for about a week. By the third or fourth week following your surgery, swelling and stiffness should subside.
- Nausea and vomiting are complications of general anesthesia, but occur infrequently. Medication can be prescribed to help control any nausea after surgery.
- Pain following TMJ surgery is usually moderate and can be controlled by medication. If intense pain persists that cannot be relieved by prescribed medication, contact your surgeon.
- Minor bleeding may occur after certain open surgical procedures, but this is easily controlled in a hospital setting. In the rare event that excessive or prolonged bleeding occurs after you return home, please contact your surgeon immediately.
- Potential nerve damage involving nerves in the area of the surgery is a possible risk of TMJ surgery. Temporary numbness or a tingling sensation may occur as small nerve fibers are regenerating and mending. Although relatively rare, some individuals may experience permanently altered sensations. There is also a possibility of temporary or permanent injury to the nerve that moves the facial muscles.
- Infection is a potential risk following any surgical procedure. If an infection does occur, it is usually treated with antibiotics. If fever, persistent swelling and pain or pus develops following surgery, please contact your surgeon immediately.
- Continuing discomfort is a potential risk of TMJ surgery, or the TMJ problem may be relieved for a period of time only to return. Correcting the contributing factors that caused the disorder will lessen the probability of the problem recurring.
- Persistent or new restrictions in range of jaw movement or function are very uncommon following TMJ surgery, and any changes should be reported to your surgeon immediately.