TMD, or Temporomandibular Joint Disorder, is a term which covers a wide range of painful oral and facial symptoms involving the jaw joint (TMJ) and the surrounding facial muscles. Symptoms may include pain in front of the ear, joint noises, headache, limited mouth opening, jaw locking, and change in bite. TMD, as it progresses, can cause symptoms affecting one’s daily quality of life. Fortunately, at the Sultan Center for Oral Facial Surgery in Ft Lauderdale, Dr. Sultan can provide both non-surgical and surgical options to treat this condition.
Many times TMD can involve a combination of a joint disorder, muscle spasm and clenching, and stress. Skeletal jaw relationships and tooth relationship (occlusion) also plays a role. When diagnosed and treated properly, the majority of patients will obtain relief from non-surgical and REVERSIBLE modalities. These include:
- Limitation of mouth opening
- Diet modification
- Moist heat
- Medications (anti-inflammatories, muscle relaxants)
- Stress management
- Bite-guard (custom)
If a bite-guard, or othotic appliance is recommended, it should be custom, made out of hard acrylic and allow your jaw to be supported and move freely.
When these non-invasive treatments fail to relieve the symptoms of TMD, and there is documented pathology in the TMJ itself, surgery should be considered.
What is an Internal Derangement?
NORMAL DISC RELATIONSHIP
The basic structure of the temporomandibular joint (TMJ) is similar to a ball and socket joint. Between the ball and socket is a cartilaginous disc (meniscus). Above and below, between the meniscus and bone lies a joint space containing lubricating (synovial) fluid. Muscles and ligaments hold the meniscus in place as the ball joint rotates and slides forward.
For a variety of causes, the meniscus can become displaced. In the early stages of Internal Derangement, joint noises can be heard (clicking/popping) but the joint may continue to function with or without pain. These noises may indicate a disc displacement WITH reduction. As the disease progresses, mouth opening may become more limited, pain more common, and potentially episodes of the jaw locking in place. As disc displacement becomes more advanced, a complete lock may occur due to a displaced disc that cannot pop back into position (disc displacement WITHOUT reduction). Left untreated, degeneration of the meniscus and arthritic changes of the bones of the joint may occur. At this time, patients may notice, in addition to the above symptoms, a change in the way their teeth meet due to changes in the dimensions of the joint.
Range of Surgical Options...
Depending on the severity of disease present, a number of surgical techniques are available:
Arthroscopy – can be either diagnostic or therapeutic. It is normally performed as an outpatient under sedation or general anesthesia. The approach involves making 2 or 3 inconspicuous puncture sites in front of the ear. Clinical conditions that respond well to this procedure include a chronically displaced disk with a locked joint. It can also be therapeutic for a patient with inflammatory arthritis. It is very difficult to anatomically reposition a displaced disc via arthroscopic surgery. The goals of this procedure are to remove inflammatory tissue from the joint, free up scar tissue, and increase joint mobility.
Arthrocentesis – an office based procedure involving the irrigation of the joint using small needles, usually performed under sedation. Reserved for patients with inflammation of the joint, or acute disc displacement.
Arthroplasty – is the classic, open surgical treatment for disc displacement. Common indications for arthroplasty are for a clicking joint or locked joint caused by a displaced disk. A small incision is placed cosmetically through a crease in front of the ear. This incision becomes inconspicuous following healing. The main requirement for this approach includes management of the disc/cartilage with a healthy mandibular condyle (ball joint). If the disk is salvageable, it can be repositioned, and then secured to the condyle with a permanent stitch. This technique, known as discopexy, works extremely well in providing improved joint function in a variety of conditions.
Fused joint (Ankylosis)
If the disc is damaged beyond repair, it must be removed. The decision to replace the disk is made at the time of surgery, either with artificial or natural material. This procedure is indicated only if the mandibular condyle is healthy, as determined by a pre-operative CT or MRI scan. Dr. Sultan normally performs this procedure in a number of Ft Lauderdale hospitals with general anesthesia with an overnight stay.
TMJ Replacement Surgery
Depending upon age, the amount of damage to the temporomandibular joint, and previous surgeries, replacement of all or part of the joint structures may be necessary. Indications for this type of surgery include:
Severe TMJ degenerative arthritis
- Severe TMJ degenerative arthritis
- Inflammatory arthritis that has not responded to other therapies
- If the tissues of the joint fuse (ankylosis) causing loss of motion in the joint, resulting in inability to open the mouth properly
- If bite changes and/or facial appearance has changed as a result of a TMJ problem
- Severe internal worsening (internal derangement) that does not respond to other therapies
- If previous attempts at surgery by opening the joint have failed to resolve the problem
- Loss of normal anatomy of the joint due to trauma or pathology of the TMJ
Types of Joint Replacements
Depending on the patient’s age and condition, this form of TMJ treatment in Ft Lauderdale, FL can be performed with either natural or artificial materials. For an actively growing patient, the use of a patient’s own rib is preferred. For an adult, we prefer the use of a metallic joint replacement, which has been shown to have long lasting success in many patients. Joint replacements can be used of standard (stock) sizes or customized (patient specific) to fit each individual patient.
Partial joint replacement
Stock Joint Replacement
Patient Specific Total Joint Replacement
The Custom Joint Replacement Process
A specially formatted CT scan is taken of the facial bones, and CT data is sent to the joint manufacturer. An extremely accurate anatomic model is manufactured from the computerized data that is used to design the implants.
Once the design process is approved by both the surgeon and the manufacturer, the joint is manufactured. Joint prostheses can be made as metal against polymer, designed by computer (CAD CAM), or by a direct wax, which is then cast as a metal against metal joint.
Patient-specific prosthesis wax-up
Titanium/PTFE patient specific prosthesis
Completed prosthesis ready for insertion
The Surgical Procedure
Although each replacement is unique for each patient’s condition, most patients can expect a 1 to 2 day stay in the hospital for any surgical TMJ treatment in Ft Lauderdale, FL. Surgical braces, or standard orthodontic appliances, are applied to line up the teeth during the procedure, and then are removed postoperatively. Patients that also have a jaw deformity or bite discrepancy may also undergo jaw repositioning at the same time. Although the jaws are not wired shut after the surgery, physical therapy is required as soon after the procedure as possible. This involves use of a hand held jaw exerciser and frequent visits to the therapist. A non-chew diet can be expected for the first 2 to 4 weeks following surgery.
Pre-op patient for joint replacement with jaw deformity
Preoperative open bite
Dr. Sultan has been specially trained in the use of both partial and total joint replacements. He has taken part in educational meetings and performed surgery both nationally and abroad. He is one of the few surgeons in South Florida experienced to perform types of TMJ treatments in Ft Lauderdale, FL.