UC HEALTH LINE: Surgery Can Offer Help to TMJ Sufferers

CINCINNATI—For those with TMJ problems, jaw pain, headaches and earaches can be a daily fact of life.

Symptoms can be treated with anti-inflammatory medications, bite splints or physical therapy techniques. But for patients with lasting TMJ pain, a consultation with an oral maxillofacial surgeon or a TMJ/oro-facial pain specialist can bring them more options to ease their condition.

The temporomandibular joint (TMJ) is a small ball and socket joint positioned just in front of the ear where the skull and lower jaw meet. It allows the lower jaw, or mandible, to move in a variety of ways and allows people to eat, swallow and speak.

But in TMJ disorders, the joint can be affected by injury, arthritis, general wear and tear or degenerative joint disease. The disk of cartilage that cushions the joint can also become damaged or displaced, leading to a loss of flexibility or range of motion for the joint. Patients often experience pain, difficulty opening and closing their jaw or even hear a "clicking” or "popping” sound when using the joint.

Deepak Krishnan, DDS, UC Health oral and maxillofacial surgeon says most common TMJ maladies are muscular, caused by habitual clenching, grinding or similar activities.

He says most patients who need surgical help have demonstrable signs and symptoms of disease within the joint.

"Some patients have symptoms that either significantly restrict the range of motion in their joint or cause hypermobility or excessive range of motion,” says Krishnan. "All such patients can benefit from surgery. Patients with muscular pain and discomfort cannot expect surgical solutions.”

The most minimally invasive technique for TMJ surgery is arthrocentesis, a short procedure usually performed under IV sedation or general anesthesia. Surgeons inject the joint with local anesthetic and fluid to flush out inflamed fluids.

"Arthrocentesis is effective when inflammation is limited to or focused most within the joint,” says Krishnan. "Washing out the joint and injecting anti-inflammatory medications within the joint gives it some respite and allows for healing.” He says patients tend to have varying results, depending on the degree of their disease.

When treatment requires open surgery, or arthroplasty, surgeons have several options, says Krishnan, including disk repositioning, discectomy and joint replacement. Because these surgeries involve more risk, including damage to the ear canal or nearby nerves, they are only used after other treatment options have been considered.

Disk repositioning: Disk repositioning is used when the cartilage disk has slipped out of place inside the joint. Once out of place, the slipped disk can cause the often noted "popping" noise inside the joint, pinch a nerve surrounding the joint or stretch or inflame the surrounding ligaments. In disk repositioning, the surgeon makes an incision, moves the displaced disk back to its original position and stitches it in place, repairing surrounding ligaments if needed. Repositioned disks can sometimes slip back or degenerate.

Discectomy: A discectomy is a full removal of the disk in the TMJ joint. Disks that are constantly out of position or pop back and forth inside the joint are good candidates for this surgery.

"Large clinical studies and collective experience have shown that discectomy is a very effective procedure in severe disc degeneration,” says Krishnan. "While it is counterintuitive not to replace the disc with anything, a fibrous scar tissue often forms around the area. Afterward, some patients may experience a gritting noise and mild teeth misalignment in joints without a disc.”

Articular eminance recontouring: For some patients, the articular eminence (the "socket” part of the TMJ’s ball and socket joint) can be too deep. In this treatment, the surgeon shortens and smooths the articular eminence to prevent excessive forces on the joint, improve range of motion and reduce pain.

"Depending on the patient’s need, the articular eminence can be reduced, eliminated or built up. In patients who have chronic dislocation issues, surgery can reduce the chances of the jaw joint head slipping out of its socket.”

TMJ replacement: Newer techniques and materials have made prosthetic replacement of the TMJ a feasible option for patients with end-stage TMJ degeneration. The replacements have a socket component made of dense polymer and a jaw joint head made of a mixed alloy material that is attached to the remaining jaw bone. Prostheses are recommended to be replaced every decade.