TMJ (Temporomandibular Joint Surgery)

About (Temporomandibular Joint Surgery)

The temporomandibular joint is the joint between the base of the skull and the lower jaw. The bone at the base of the skull is called the temporal bone, and the lower jaw is called the mandible. Frequently, the temporomandibular joint is just called the TMJ. In actuality, everybody has 2 TMJ’s, 1 on the right and 1 on the left, and when the jaw moves, both joints move. TMJ disorders can be caused by several things, including trauma, malocclusion, stress, grinding the teeth and skeletal growth deformity. Some systemic diseases such as rheumatoid arthritis can also affect the TMJ’s.

Two main categories of TMJ disorders exist. The first is called myofacial pain dysfunction. This usually involves spasms and pain associated in the muscles that move the joint, such as in the temporal area or along the jaw line; however, the joint itself is usually non-tender. Patients may experience some associated neck and shoulder pain and the muscle spasms are usually related to some type of stress, trauma or malocclusion (bad bite). The treatment for myofacial dysfunction involves physical therapy muscle relaxants and possibly a splint between the teeth in order to help relax the muscles and achieve a balanced bite. Further treatment may involve orthodontics and jaw surgery, or a crown and bridge to help stabilize the bite.

The second type of TMJ disorder involves a true internal derangement of the emporomandibular joint. Inside the joint is a disc, and this disc slides on top of the articular head of the lower jawcalled the condyle as the mouth opens. It is possible for this disc to be displaced resulting inaccompanying joint sounds such as popping and clicking. Many people have pops and clicks intheir joints without degenerative changes, and degenerative changes are usually signaled by painin the joint. The disc may be completely dislocated anterior to the joint so that opening is limited. With internal derangement, associated muscle pain may occur, but usually pain exists directly in front of the ear, and patients find it beneficial to eat a soft diet. Usually magnetic resonance imaging (MRI) is needed in order to confirm the diagnosis of an internal derangement in the joint. Internal derangements, like myofacial dysfunction, can be treated with physical therapy, muscle relaxants, and splint therapy. If, however, the conservative measures fail, TMJ Surgery may be necessary.

The Operation:

Surgery on the TMJ is usually performed under a general anesthetic on an outpatient basis.

One surgery uses an arthroscopic procedure in which 2 small holes are made in front of the ear; a scope is passed into the joint space, and the joint is explored. This helps with the diagnosis, as well as irrigating the joint free of any debris. Instruments can be used in conjunction with the scope in order to break up any adhesions (arthritic scarring) inside the joint and to help mobilize the disc. The incisions are closed with sutures that are removed in 1 week. Physical therapy will usually begin 1 week following the surgery.

The next type of TMJ Surgery involves making a larger incision in front of the ear and exploring the joint directly. The incision in front of the ear is usually very esthetic and in the same position as a facelift incision. With an open joint procedure, it is actually possible to reposition the disc. Occasionally, if the disc is completely degenerated or torn, it must be completely removed. Historically, various materials have been used to replace the disc, including synthetic materials, ear cartilage, and temporalis fascia muscle (the large “biting” muscle on the side of the head). However, many times it is not necessary to replace the disc at all if physical therapy can be maintained in order to keep the bones and the joint from fusing together.

The third type of TMJ Surgery involves total reconstruction of the TMJ. The reconstruction is typically performed using rib cartilage or a portion of the collar bone. The reconstruction involves not only an incision in front of the ear, but also one in the lower part of the jaw just onto the neck. The bone is then held into position using bone screws, and it may be necessary to wire the teeth together for a short period of time. The TMJ may also be reconstructed using an artificial prosthesis (artificial joint). Few prostheses are currently available, and your surgeon must choose one with a good track record. Orthognathic surgery (surgery to correct jaw growth problems) is sometimes used before or soon after TMJ Surgery in order to help position the jaw into a more stable position to decrease the internal forces inside the joint.

Recovery

Immediately after surgery, a moderate amount of swelling will occur which lasts approximately 3 to 4 days before it begins to go down. Depending on the extent of surgery, some bruising may appear in front of the ear or onto the neck and cheek. If a rib graft is harvested, you may have a little bit of discomfort in taking a full, deep breath; however, deep breathing is important so that the lungs do not develop an infection. The sutures are removed after 1 week, and if the teeth are not wired together, physical therapy is begun at that time. This initially involves some stretching and mobility exercises in order to keep the joint from scarring. The importance of physical therapy cannot be overemphasized, and when patients do not follow the physical therapy regimen, they are not able to open their mouths as far. After surgery, you will most likely be prescribed a course of antibiotics, steroids and pain medicine. A non-steroidal anti-inflammatory agent will also be given on a longer term basis during the healing phase.

Complications

Possible complications of TMJ surgery include continued degenerative changes inside the joint with little relief from pain or little improvement in function. Bleeding, infection, and nerve injury may follow surgery, including numbness in front of the ear or damage to the nerve which moves the eyebrow and/or the lower lip. Surgery may change the bite and/or damage the teeth. A risk associated with harvesting rib grafts is that the lungs may partially deflate, requiring use of a tube to reinflate the lungs through the outside of the chest.

Pre-operative Instructions

1. Do not eat or drink anything after midnight the night before surgery so that your stomach is completely empty. If you are likely to be nauseated, consult with your surgeon about medications you can take before surgery.
2. Wear loose, comfortable clothing that is easy to put on and take off.
3. Bring someone with you who can take you home and be with you for the first 48 hours following surgery.
4. Take no aspirin products or vitamin E 2 weeks before surgery, unless otherwise directed by your surgeon.
5. Begin taking 1000 mg vitamin C , in four 250 mg doses, daily 1 month prior to surgery.
6. Prepare for any physical therapy that may be necessary following surgery.

Post-operative Instructions

1. Keep head elevated on 2 pillows for 2 weeks or sleep in a lounge chair so the head remains elevated.
   
2. Apply ice to the face in front of the ear for the first 24 to 36 hours.
3. Eat a “non-chew,” soft diet until instructed to do otherwise.
4. Take medication as directed.
5. Apply ointment as directed to the incision sites.
6. If a rib graft was taken, make sure to take deep breaths at least 4 times per day for 5  minutes to decrease the chance of lung infections.
7. Beginning 1 week following surgery, perform physical therapy stretching exercises as directed. Taking your pain medicine or anti-inflammatory agents at least 30 minutes prior to beginning physical therapy can be helpful. Apply heat to the face for approximately 10 to 15 minutes before stretching exercises.
8. Call your surgeon with any questions and especially if any of the following occur:  temperature is over 101.0° F, excessive bleeding or rapid swelling occurs, pain is unrelieved by prescribed pain medications, breathing is difficult, or if you experience sudden shift of the bite.
9. Continue multi-vitamins and 1,000 mg vitamin C, in four 250 mg doses, daily for 6 weeks after surgery.